Coping strategies for oral health problems by people with schizophrenia

Aim

To explore coping strategies used by PWS in oral health in order to more understand and to best involve them in the management of their own oral health in daily life.

Protocol and registration

Neither a review registration nor a review protocol was completed. This systematic review is reported in accordance with Cochrane Handbook [21] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements for reporting systematic reviews of health sciences [22].

Eligibility criteria

Based on the Participants–Intervention– Comparison–Outcome–Study (PICOS) method, we included cross-sectional and longitudinal quantitative and qualitative studies that1) examined coping strategies regarding oral health in PWS or 2) examined coping strategies were used in dental care. We included studies conducted with at least one PWS aged 18 years old more and without restriction on sex, socioeconomic status, or language. We excluded conference, abstracts, reviews and editorials.

Data sources and search strategy

A comprehensive search was conducted up to December 15, 2018 by using systematic database searches of PUBMED (provided by National Center for Biotechnology Information, Medicine), PsycINFO (provided by EBSCOhost), SCOPUS (provided by Elsevier), LILACS (provided by BIREME-PAHO-WHO), GREY Literature Report (provided by The New York Academy Medicine) and Cochrane Library (provided by WILEY). The search strategy was developed with the assistance of a specialized health sciences librarian at the University of Reims, France.

First, we established the search terms on PubMed: (“Oral Health”[Mesh]) OR “Schizophrenia/ rehabilitation”[Mesh]) AND “Adaptation, Psychological”[Mesh]AND “Resilience”). The search for PsycINFO, SCOPUS, LILACS, GREY Literature Report and Cochrane Library were built of TITLE-ABS-KEY (schizophrenia) OR TITLE-ABS-KEY (oral AND health) AND TITLE-ABS-KEY (coping) OR TITLE-ABS-KEY (adaptation AND psychological) AND TITLE-ABS-KEY (resilience) AND TITLE-ABS-KEY (rehabilitation)).

Manual screening was then completed by searching through bibliographies and reference lists of the included papers to determine potential papers that were not found in the electronic search. Finally, a grey literature search was conducted by using Google Scholar and Google search engine.

Study selection

Two reviewers (FSP and FD) independently screened the list of titles and abstracts to identify the potentially relevant papers based on the inclusion criteria. If the abstracts were judged to contain insufficient information, then the full studies were reviewed to decide whether they should be included based on the selection criteria. When a discrepancy in the selection decision occurred, the two reviewers engaged in discussion until a consensus was reached. If needed, a third reviewer (NR) resolved the possible conflicts concerning eligibility.

Data extraction and data items

Two reviewers (FSP and FD) independently extracted data from the selected papers on the following items: Coping/adaptation, psychological, resilience, schizophrenia/ rehabilitation and oral health.

Risk of bias in individual studies

Two reviewers (FSP and FD) independently assessed the methodological quality of the selected studies by using The Newcastle-Ottawa Scale [23] for cohort, cross-sectional, and case control studies; and the Critical Appraisal Skills Programme (CASP) checklist for qualitative studies [24].

Study inclusion

An initial search identified 28 studies. After checking the title and reading the abstract 20 studies were excluded based on inclusion and exclusion criteria, and 8 studies were included in the review. Nothing else was found in grey literature. The PRISMA flow diagram that illustrates the search process [22] is presented in Figure 1.

Figure 1

PRISMA flowchart of the identification process of included studies

Characteristics of included studies

Of the 8 studies, all were qualitative and were written in English. These studies were conducted in Brazil (n = 1), Sweden (n = 1), China (n = 1), Romania (n = 1), Australia (n = 2), Taiwan (n = 1), and Switzerland (n = 1). A detailed description of the included studies is presented in Table 1.

Synthesis of results

Due to the heterogeneity of the included studies, findings were evaluated in a descriptive manner. Differents thematic emerged:

• Neuropsychological functioning,

• Resilience,

• Sense of coherence,

• Sense and hope,

• Sense of personal responsibility and self-determination,

• Self-esteem, self confidence, stigmatisation,

• Stress,

• Social support/peer support

• Religious and spirituallity

Neuropsychological functioning

To date, there have been relatively few studies aiming at establishing the relationship between neuropsychological functioning and coping strategies in schizophrenia. Nicholson et al. , suggested that neuropsychological deficits may interfere with the ability of individuals with schizophrenia to access effective coping skills or to use these mechanisms in a flexible, adaptive manner [25]. It is possible that problem solving skills, planning, abstract thinking, and the ability to access stored knowledge and strategies are the necessary cognitive prerequisites for engaging in activities that help people to redefine their lives and cope with the stressors associated with having a mental illness [26,27]. Kelly et al. 2015, showed that, coping style (specifically emotion-focused) was a more consistent predictor of perceived stress in the healthy control group than with persons with experience of a first-episode psychosis. This suggests that neuropsychological functioning (cognitive deficits in PWS) impact the flexibility with which individuals are able to select and apply a variety of coping strategies, as well as limit the use of active coping [28].

Resilience

According to Grotberg et al., the resilience concept may play a role as a potentiating agent in adaptation to a problem, like tooth loss for example. Resilient behavior is associated with better adaptive abilities (such as coping) when facing adversities and incorporates interactions between diverse factors [29].

Resilience is a dynamic concept indicating that some individuals have a relatively good outcomes despite having experienced serious stresses or personal problems with a high resilience level. They also have better results in daily life than that of other individuals who suffered the same experiences [30]. A study of older adults reported the relationship between adaptive strategies following adverse events (tooth loss) and a positive oral health self-perceived. This suggests that a person with high resilience can cope with a negative fonctional evenement in a acceptable manner [31].

Sense of coherence

Antonovsky et al., [32] introduced the concepts of sense of coherence (SOC) and general resistance resources (GRRs). Their study claims that peoples’ life orientation will have an impact on health and try to find the solution to the salutogenic question : why some people, regardless of major stressful situations and severe hardships, stay healthy, and use coping strategies while others do not ?

The SOC refers to an enduring attitude and measures how people view life and identify and use their GRRs (e.g. self‐esteem, intelligence) in stressful situations. A person with a strong SOC has many different GRRs and more importantly the ability to use these resources in a healthy direction (i.e. coping health behavior). Previous studies have demonstrated a strong relationship between SOC and dimensions of general health such as mental health [33,34], well-being and quality of life [33], and a weaker relationship between SOC and physical health [33]. Elias et al., showed that individuals with a strong or moderate SOC had significantly fewer oral health-related problems and thereby better oral health-related quality of life [35].

Sense of hope

According to Snyder et al., hope is related to the life goals and expectations of a positive outcome of people’s own effort [36,37]. This concept of hope includes emotion, motivation, behavior and cognition [38]. Hope is an anticipation of a future which is good and based upon mutuality (relationships with others), self-steem competence, coping strategies, psychological well-being, purpose and meaning in life, as well as a sense of ‘’the possible’’. The basic level of hope remains relatively stable over time, which makes it resemble a personality trait. In PWS, the relationships among hope, depression, and self-stigma, sense of personal responsibility and self-determination are interconnected [39,40,41]. This relationship is illustrated with two adaptive tasks, which are common across situations that threaten physical or psychological well-being, managing uncertainty and coping with a changing reality. Coping fosters hope when it is at low ebb as well as ways in which hope fosters and sustains coping over the long term [42].

Sense of personal responsibility and self-determination

Neither PWS nor their families have been involved in decision-making on dental health services, and they continue to be at risk of social exclusion and discrimination in their oral health care [43]. The experience of oral health for PWS can have lasting effects on a person’s sense of identity and self-worth the internalization of stigma. There is also evidence that the lack of influence or control on their care can lead to poor health outcomes. Conversely, the ability to exercise control and influence, even when high stress is present, can act as a protective factor against levels of disease risk. Powerlessness has emerged as a key risk factor in the etiology of disease, and evidences from a number of different fields suggest that empowerment is not just a set of values but also leads to recovery. Empowerment includes increased emotional wellbeing, independence in decision making, motivation to participate in health care and take care himselve and more effective coping strategies [39,44].

Self-esteem, self confidence, stigmatisation

Self-esteem is an individual (emotional) evaluation of people’s own worth, so encompasses an implicit judgment of people’s ability to face life’s challenges (problem solving) that affects how you perceive stressors and deal with them (coping process). The adaptative coping strategies, were positively related to stigma resistance, self-stigma, self-esteem, self-reflection, and coping was significantly associated with higher stigma resistance [45]. The relationship between oral and general health is complex, particularly in PWS. Oral diseases affect the patient’s quality of life through social and psychological impacts such as the deterioration of the aesthetic of their smile, which leads to lower their self-esteem and self-confidence [46,47].

Stress

Individuals with schizophrenia often report and demonstrate significant difficulty coping with life stresses [48,49] compared to people without a mental illness. PWS often employ a more limited range of coping strategies, which are characterized by a preference for avoidance and passive coping rather than help seeking or active problem-solving approaches [50,51].

Stress is a rather complex concept. However, effective coping enables people to be engaged in activities that may involve stress, such as dentist visits, which is one reason for their infrequent dentist visits [52]. Stress is subjective both in the measurement of severity and experience. The way in which individuals perceive and interpret stressors may vary greatly [53].

Two processes emerged, the perception of the nature and degree of risk divided into “threat” and “challenge” evaluations and the perception of resources or abilities to cope with the stressor.

Kelly et al., suggested that although coping style and neuropsychological functioning are important predictors of perceived stress by PWS, additional factors need to be considered such as social support, expressed emotion, self-esteem, resilience and self-efficacy as trait negative affectivity is significantly related to coping styles and stress reactivity in schizophrenia [28].

Social Support /Peer support

Social supports develop self-esteem based on the feedback of individuals from the environment as a result of social interactions [54,55]. A personal support network is essential for coping, building and maintaining resilience. Encouragement and support from these relationships is extremely effective in helping people work through stressful periods. Peers can be a vitally important component of support network, because they are likely to be experiencing similar stresses [39].

Religious and spirituallity

Religious coping is multidimensional and refers to functionally oriented expressions of religion in times of stress. Religious coping is operationally defined as “the use of religious beliefs or behaviors to facilitate problem-solving to prevent or alleviate the negative emotional consequences of stressful life circumstances” [56]. Carver et al. [57] suggested that the value of positive reinterpretations is that it not only reduces distress, but also can be used to reappraise a stressful situation and see it more positively.

Studies revealed that adaptive coping strategies were significantly associated with religious and spirituallity as resource of finding meaning and hope were identified as a key component of the process of psychological recovery [58,59,60].

All of this these metacognitive processes are summarized in Figure 2.

Figure 2

Metacognitive process in oral health for person with schizophrenia