DOI: 10.1111/ipd.12118
Oral health-related quality of life of schoolchildren: impact of clinical and psychosocial variables HELENA SILVEIRA SCHUCH1, FRANCINE DOS SANTOS COSTA1, DIONE DIAS TORRIANI1, ´ VIO FERNANDO DEMARCO1,2 & MARI´LIA LEA˜O GOETTEMS1 FLA 1
Post-Graduate Program in Dentistry, Federal University of Pelotas, Pelotas, Brazil, and 2Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
International Journal of Paediatric Dentistry 2015; 25: 358–365 Background. Besides
the clinical aspects, the patient’s perspective of oral health-related quality of life (OHRQoL) may be influenced by a series of individual characteristics. Aim. The aim was to investigate the impact of clinical and psychosocial variables on the OHRQoL of Brazilian schoolchildren. Design. A school-based cross-sectional study was conducted with children of 8–10 year old attending public (15) and private (5) schools (n = 749). Questionnaires were applied to parents to obtain socioeconomic characteristics, and children were interviewed. Assessment of OHRQoL was per-
Introduction
During childhood and adolescence, the occurrence of oral diseases is closely related to an impaired perception on daily activities and quality of life. The presence of untreated cavities in dentine and their consequences, that is, abscess and pulp exposure, history of extraction, and toothache, have shown to be associated with negative impact on oral health-related quality of life (OHRQoL)1. Similarly, the occurrence of untreated dental trauma2 and malocclusion3 has been associated with a negative impact on oral healthrelated quality of life. Besides the clinical aspects, the patient’s perspective captured via OHRQoL assessment may be influenced by a series of individual characteristics, including socioeconomic and psychosocial variables. Cohen-Carneiro et al.4 Correspondence to: Marılia Le~ao Goettems, Faculdade de Odontologia/UFPel, Rua Goncßalves Chaves 457, 4° andar, Centro, Pelotas-RS 96015560, Brazil. E-mail: [email protected]
358
formed using the Child Perceptions Questionnaire 8–10 (CPQ). Oral health examinations included periodontal condition, dental caries, dental trauma, and malocclusion assessment. Unadjusted analyses were undertaken using t-tests and oneway analysis of variance. Multiple linear regression was used to assess the effects of independent variables on CPQ scores. Results. Factors associated with higher CPQ scores in the linear regression analysis after adjustments were family income, presence of decayed teeth, self-reported dental trauma, dental fear, and dental pain. Conclusion. Oral health-related quality of life was influenced by psychosocial and clinical variables.
reviewed the literature about the association between social indicators and impact on oral health-related quality of life (OHRQoL) of individuals and populations, showed that the social conditions most clearly associated with the perception of negative impact on OHRQoL were female gender, low education, and low income, being immigrants or belonging to minority ethnic groups4. Dental fear and anxiety were also showed critical for the well-being of children and adolescents. Moraes et al.5 showed that fear and anxiety are related, but the fear is part of child development and, in general, is transient, but may persist for long periods. On the other hand, the anxiety corresponds to a response to situations where the source of threat to is not well defined, being necessary to strategy to prevent it or alleviate it. Luoto et al.6 observed that children with dental fear had significant impact on the social and emotional well-being. Also, Carrillo-Diaz et al.7 observed that low scores on emotional wellbeing are associated with a negative self-rated oral health and high levels of dental anxiety.
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Schoolchildren oral health related quality of life
The influence of psychosocial variables, besides the clinical conditions, on patients perception is expected, as oral OHRQoL is a multidimensional construct that includes a subjective evaluation of an individual’s oral health, functional well-being, emotional wellbeing, expectations and satisfaction with care, and sense of self8. Information on patient’s perception may allow researchers and clinicians to better define appropriate treatment goals and outcomes resulting in important benefits for individual patients, communitybased dental practices, clinical research, and potentially public health policy. This study aims to investigate the impact of clinical and psychosocial factors on oral health-related quality of life of Brazilian schoolchildren. Material and methods
Design and sampling procedure This cross-sectional study was performed with children aged 8–10 years attending both private and public schools, in Pelotas/RS – Brazil. Pelotas has a population of approximately 305,700 people, of which 25,628 are schoolchildren. A two-stage stratified sample design was adopted for sample selection. There are 25 private and 91 public schools in Pelotas for children in this age range. To ensure proportionality, in the first stage, five private and 15 public schools were randomly selected using a probability selection method where probability was proportional to school size. In the second stage, five classes were randomly selected in each school. All students in the selected classes were invited to participate. Sample size needed to test associations between the clinical indicators for the dental examination and OHRQoL scores was estimated using the following parameters: sampling error of 5%, 95% confidence level (CI), and mean Child Perception Questionnaire 8–10 (CPQ) score of 9.6 (SD = 7.3) in the unexposed group and 12.6 (SD = 10.1) in the exposed group, based on previous study9. A correction factor of 1.6 was applied because of a change in the precision of estimates generated by the process of clusters in two stages (design effect) and a
359
total of 20% was added considering possible losses, resulting in a required minimum of 521 children. The epidemiological survey comprehended a larger sample, with participants of 8–12 years old; however, in this study, only children aged 8–10 years, who were eligible to answer the CPQ8–10 to assess oral health-related quality of life questionnaire, were included. Information about methodological details and other oral health outcomes in this population has been reported elsewhere10. Children unable to cooperate or respond to interview were excluded. Data collection Data collection consisted of a questionnaire sent to parents by children, interview, and clinical examination of children. The pretested questionnaire was sent home to obtain socioeconomic and sociocultural information. The level of maternal education was measured in years of education, and family income was measured in Brazilian Reais (R$ 1 = U.S. $ 0.45). Children whose parents answered the interview participated in the data collection at school. Each school was visited as many times as necessary until the losses did not exceed 10%. Questionnaires were administered to children by trained interviewers, which included questions relating to demographic characteristics (age and gender), family structure, history of dental trauma, dental pain in the last 6 months, dental fear, and assessment of oral health-related quality of life. Family structure was considered nuclear if child lives with both parents and non-nuclear if the child lives with only one of the parents or with a tutor. Children responded about the occurrence of dental pain in the last 6 months preceding the survey, using the question ‘Have you had toothache in the last 6 months?’, with answers being ‘yes’ or ‘no’11. Dental fear was assessed using the Dental Anxiety Question (DAQ)12 ‘Are you afraid of the dentist?’. The following possible answers were provided: (1) No; (2) Yes, a little; (3) Yes; and (4) Yes, a lot. The outcome was dichotomized as ‘children without dental fear’
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
360
H. S. Schuch et al.
(for answers 1 and 2) and ‘children with dental fear’ (for answers 3 and 4). Skin color was collected based on examiner perception and classified as ‘white’ or ‘non-white’. The CPQ8–1013 was used to evaluate the oral health-related quality of life. The instrument consists of 25 questions organized into four domains: oral symptoms (n = 5), functional limitations (n = 5), emotional well-being (n = 5), and social welfare (n = 10), which were validated by Jokovic et al.13 and adapted to Brazil by Martins et al.14 CPQ items referred to the frequency of events during the previous 3 months. Response options and scores were: ‘Never’ (scoring 0), ‘Once or twice’ (scoring 1), ‘Sometimes’ (scoring 2), ‘Often’ (scoring 3), and ‘Every day or almost every day’ (scoring 4). An overall CPQ8–10 score was computed by summing all of the item scores, and scores for each of the four domains were computed. The clinical examination was performed in regular school chairs by six post-graduate dental students, previously trained and calibrated, using protective equipment (gloves, mask, and apron), artificial light, dental mirror, and CPI probes, following procedures recommended by the WHO15: initial assessment of periodontal condition using the Dental Plaque Index (DPI)16, which considers the presence of plaque on tooth surfaces, and the Gingival Bleeding Index16, which assesses the presence of bleeding after probing four sites in each tooth (mesiobuccal, mid-buccal, distobuccal, and lingual). For both indexes, six teeth were evaluated – first molars and incisors of the diagonal quadrants. After the oral hygiene evaluation, teeth were cleaned with dental gauze as and when necessary and dental caries were assessed using the DMFT (decayed, missing, and filled teeth) Index. The O’Brien Index17 was used to evaluate the presence of dental trauma. Malocclusions were evaluated using the Dental Aesthetic Index15, which considers a combination of measures to determine the degree of malocclusion and need for treatment. The fluorosis was assessed using the Index of Dean18, and enamel defects were assessed using the Index of FDI for enamel defects19.
Ethical aspects The Human Research Ethics Committee, School of Dentistry, Federal University of Pelotas (Protocol n. 101/2009), approved the research project. The guardians signed the informed consent form. Children who needed dental treatment were referred to the Dental School. Data analysis Simple descriptive statistics were generated. Unadjusted analyses were undertaken using t-tests and one-way analysis of variance to assess the associations between CPQ scores and the independent variables, including clinical, demographic, socioeconomic, and psychosocial variables. Multiple linear regression models using ‘forward stepwise’ entry procedures were used to assess the independent effects of variables on CPQ scores. To manage confounding20, all variables derived from the clinical examination and parental questionnaire were included in model fitting irrespective of whether or not they showed significant associations with CPQ scores at the unadjusted analysis. For final model, the variables were considered significant if they had a P-value ≤0.05 after adjustment. Age and sex were entered and retained in the final models, whether the variables were significant or not. Results
A total of 1086 children aged 8–10 years were eligible for the study, of which 337 did not present the informed consent form signed by parents or were absent from school during data collection. The final response rate was therefore 69.0%, giving a total sample of 750 children. CPQ scores ranged from 0 to 68, with an average of 14.11 (SD = 10.95). Emotional well-being was the domain with largest variation (0–20), and the oral symptoms domain had the highest mean (5.14) (Table 1).
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Schoolchildren oral health related quality of life
Table 1. Descriptive distribution of overall and domainspecific CPQ scores (n = 750). Pelotas/2010. Number of items
Mean CPQ scores (SD)
Possible range
Range
25
14.11 (10.95)
0–100
0–68
5
5.14 (3.06)
0–20
0–15
5
2.65 (3.04)
0–20
0–17
5
3.35 (3.84)
0–20
0–20
10
2.98 (4.06)
0–40
0–26
Table 2. Sample distribution and mean CPQ score (n = 750). Pelotas/2010.
Variable Total CPQ Domains Oral symptoms Functional limitation Emotional well-being Social well-being
CPQ, Child Perceptions Questionnaire; SD, standard deviation.
Table 2 shows the distribution of the sample and the association of the independent variables with mean of CPQ score. The majority (75.8%) was white-skinned females (53.9%) and came from nuclear families (64.8%). Demographic and socioeconomic characteristics that were associated with oral health-related quality of life scores were skin color (P < 0.001), with non-white skin children presenting higher CPQ scores, maternal education (P < 0.001), with children whose mothers had less than 8 years of schooling reporting worst oral health-related quality of life, and family income, with children from low-income families presenting higher scores. Family structure (P = 0.003) and household crowding (P = 0.007) were also associated with CPQ: Children from non-nuclear families and from overcrowded housing reported impaired oral health-related quality of life, compared with their counterparts. In addition, children who reported dental fear and who had experienced dental pain in the last 6 months presented higher CPQ scores (P < 0.001). Associations between the clinical indicators derived from the dental screening and oral health-related quality of life scores are presented on Table 3. Self-reported dental trauma was shown to be associated with worst impact on oral health-related quality of life (P < 0.001), as well as experience of dental caries (P = 0.002) and the presence of decayed teeth in the moment of the dental examination (P < 0.001). Also, children with DPI higher than 5 (P = 0.002) and presenting
361
Sex Male Female Age 8 9 10 Skin color White Non-white Maternal schooling >8 years ≤8 years Familiar income 1 (R$ 1020–12,000) 2 (R$ 580–1019) 3 (R$ 0–580) Family structure Nuclear Non-nuclear Household crowding 1st (2–4) 2nd (5–6) 3rd (7–15) Dental fear No Yes Dental pain Absent Present
n (%)
Mean CPQ8–10 score (SD)
353 (47.07) 397 (53.93)
13.34 (10.31) 14.80 (11.46)
0.069
171 (22.80) 295 (39.33) 284 (37.87)
12.62 (9.91) 14.63 (11.81) 14.48 (10.57)
0.211
552 (75.82) 176 (24.18)
13.18 (10.38) 17.17 (12.36)
Oral health-related quality of life of schoolchildren: impact of clinical and psychosocial variables HELENA SILVEIRA SCHUCH1, FRANCINE DOS SANTOS COSTA1, DIONE DIAS TORRIANI1, ´ VIO FERNANDO DEMARCO1,2 & MARI´LIA LEA˜O GOETTEMS1 FLA 1
Post-Graduate Program in Dentistry, Federal University of Pelotas, Pelotas, Brazil, and 2Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
International Journal of Paediatric Dentistry 2015; 25: 358–365 Background. Besides
the clinical aspects, the patient’s perspective of oral health-related quality of life (OHRQoL) may be influenced by a series of individual characteristics. Aim. The aim was to investigate the impact of clinical and psychosocial variables on the OHRQoL of Brazilian schoolchildren. Design. A school-based cross-sectional study was conducted with children of 8–10 year old attending public (15) and private (5) schools (n = 749). Questionnaires were applied to parents to obtain socioeconomic characteristics, and children were interviewed. Assessment of OHRQoL was per-
Introduction
During childhood and adolescence, the occurrence of oral diseases is closely related to an impaired perception on daily activities and quality of life. The presence of untreated cavities in dentine and their consequences, that is, abscess and pulp exposure, history of extraction, and toothache, have shown to be associated with negative impact on oral health-related quality of life (OHRQoL)1. Similarly, the occurrence of untreated dental trauma2 and malocclusion3 has been associated with a negative impact on oral healthrelated quality of life. Besides the clinical aspects, the patient’s perspective captured via OHRQoL assessment may be influenced by a series of individual characteristics, including socioeconomic and psychosocial variables. Cohen-Carneiro et al.4 Correspondence to: Marılia Le~ao Goettems, Faculdade de Odontologia/UFPel, Rua Goncßalves Chaves 457, 4° andar, Centro, Pelotas-RS 96015560, Brazil. E-mail: [email protected]
358
formed using the Child Perceptions Questionnaire 8–10 (CPQ). Oral health examinations included periodontal condition, dental caries, dental trauma, and malocclusion assessment. Unadjusted analyses were undertaken using t-tests and oneway analysis of variance. Multiple linear regression was used to assess the effects of independent variables on CPQ scores. Results. Factors associated with higher CPQ scores in the linear regression analysis after adjustments were family income, presence of decayed teeth, self-reported dental trauma, dental fear, and dental pain. Conclusion. Oral health-related quality of life was influenced by psychosocial and clinical variables.
reviewed the literature about the association between social indicators and impact on oral health-related quality of life (OHRQoL) of individuals and populations, showed that the social conditions most clearly associated with the perception of negative impact on OHRQoL were female gender, low education, and low income, being immigrants or belonging to minority ethnic groups4. Dental fear and anxiety were also showed critical for the well-being of children and adolescents. Moraes et al.5 showed that fear and anxiety are related, but the fear is part of child development and, in general, is transient, but may persist for long periods. On the other hand, the anxiety corresponds to a response to situations where the source of threat to is not well defined, being necessary to strategy to prevent it or alleviate it. Luoto et al.6 observed that children with dental fear had significant impact on the social and emotional well-being. Also, Carrillo-Diaz et al.7 observed that low scores on emotional wellbeing are associated with a negative self-rated oral health and high levels of dental anxiety.
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Schoolchildren oral health related quality of life
The influence of psychosocial variables, besides the clinical conditions, on patients perception is expected, as oral OHRQoL is a multidimensional construct that includes a subjective evaluation of an individual’s oral health, functional well-being, emotional wellbeing, expectations and satisfaction with care, and sense of self8. Information on patient’s perception may allow researchers and clinicians to better define appropriate treatment goals and outcomes resulting in important benefits for individual patients, communitybased dental practices, clinical research, and potentially public health policy. This study aims to investigate the impact of clinical and psychosocial factors on oral health-related quality of life of Brazilian schoolchildren. Material and methods
Design and sampling procedure This cross-sectional study was performed with children aged 8–10 years attending both private and public schools, in Pelotas/RS – Brazil. Pelotas has a population of approximately 305,700 people, of which 25,628 are schoolchildren. A two-stage stratified sample design was adopted for sample selection. There are 25 private and 91 public schools in Pelotas for children in this age range. To ensure proportionality, in the first stage, five private and 15 public schools were randomly selected using a probability selection method where probability was proportional to school size. In the second stage, five classes were randomly selected in each school. All students in the selected classes were invited to participate. Sample size needed to test associations between the clinical indicators for the dental examination and OHRQoL scores was estimated using the following parameters: sampling error of 5%, 95% confidence level (CI), and mean Child Perception Questionnaire 8–10 (CPQ) score of 9.6 (SD = 7.3) in the unexposed group and 12.6 (SD = 10.1) in the exposed group, based on previous study9. A correction factor of 1.6 was applied because of a change in the precision of estimates generated by the process of clusters in two stages (design effect) and a
359
total of 20% was added considering possible losses, resulting in a required minimum of 521 children. The epidemiological survey comprehended a larger sample, with participants of 8–12 years old; however, in this study, only children aged 8–10 years, who were eligible to answer the CPQ8–10 to assess oral health-related quality of life questionnaire, were included. Information about methodological details and other oral health outcomes in this population has been reported elsewhere10. Children unable to cooperate or respond to interview were excluded. Data collection Data collection consisted of a questionnaire sent to parents by children, interview, and clinical examination of children. The pretested questionnaire was sent home to obtain socioeconomic and sociocultural information. The level of maternal education was measured in years of education, and family income was measured in Brazilian Reais (R$ 1 = U.S. $ 0.45). Children whose parents answered the interview participated in the data collection at school. Each school was visited as many times as necessary until the losses did not exceed 10%. Questionnaires were administered to children by trained interviewers, which included questions relating to demographic characteristics (age and gender), family structure, history of dental trauma, dental pain in the last 6 months, dental fear, and assessment of oral health-related quality of life. Family structure was considered nuclear if child lives with both parents and non-nuclear if the child lives with only one of the parents or with a tutor. Children responded about the occurrence of dental pain in the last 6 months preceding the survey, using the question ‘Have you had toothache in the last 6 months?’, with answers being ‘yes’ or ‘no’11. Dental fear was assessed using the Dental Anxiety Question (DAQ)12 ‘Are you afraid of the dentist?’. The following possible answers were provided: (1) No; (2) Yes, a little; (3) Yes; and (4) Yes, a lot. The outcome was dichotomized as ‘children without dental fear’
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
360
H. S. Schuch et al.
(for answers 1 and 2) and ‘children with dental fear’ (for answers 3 and 4). Skin color was collected based on examiner perception and classified as ‘white’ or ‘non-white’. The CPQ8–1013 was used to evaluate the oral health-related quality of life. The instrument consists of 25 questions organized into four domains: oral symptoms (n = 5), functional limitations (n = 5), emotional well-being (n = 5), and social welfare (n = 10), which were validated by Jokovic et al.13 and adapted to Brazil by Martins et al.14 CPQ items referred to the frequency of events during the previous 3 months. Response options and scores were: ‘Never’ (scoring 0), ‘Once or twice’ (scoring 1), ‘Sometimes’ (scoring 2), ‘Often’ (scoring 3), and ‘Every day or almost every day’ (scoring 4). An overall CPQ8–10 score was computed by summing all of the item scores, and scores for each of the four domains were computed. The clinical examination was performed in regular school chairs by six post-graduate dental students, previously trained and calibrated, using protective equipment (gloves, mask, and apron), artificial light, dental mirror, and CPI probes, following procedures recommended by the WHO15: initial assessment of periodontal condition using the Dental Plaque Index (DPI)16, which considers the presence of plaque on tooth surfaces, and the Gingival Bleeding Index16, which assesses the presence of bleeding after probing four sites in each tooth (mesiobuccal, mid-buccal, distobuccal, and lingual). For both indexes, six teeth were evaluated – first molars and incisors of the diagonal quadrants. After the oral hygiene evaluation, teeth were cleaned with dental gauze as and when necessary and dental caries were assessed using the DMFT (decayed, missing, and filled teeth) Index. The O’Brien Index17 was used to evaluate the presence of dental trauma. Malocclusions were evaluated using the Dental Aesthetic Index15, which considers a combination of measures to determine the degree of malocclusion and need for treatment. The fluorosis was assessed using the Index of Dean18, and enamel defects were assessed using the Index of FDI for enamel defects19.
Ethical aspects The Human Research Ethics Committee, School of Dentistry, Federal University of Pelotas (Protocol n. 101/2009), approved the research project. The guardians signed the informed consent form. Children who needed dental treatment were referred to the Dental School. Data analysis Simple descriptive statistics were generated. Unadjusted analyses were undertaken using t-tests and one-way analysis of variance to assess the associations between CPQ scores and the independent variables, including clinical, demographic, socioeconomic, and psychosocial variables. Multiple linear regression models using ‘forward stepwise’ entry procedures were used to assess the independent effects of variables on CPQ scores. To manage confounding20, all variables derived from the clinical examination and parental questionnaire were included in model fitting irrespective of whether or not they showed significant associations with CPQ scores at the unadjusted analysis. For final model, the variables were considered significant if they had a P-value ≤0.05 after adjustment. Age and sex were entered and retained in the final models, whether the variables were significant or not. Results
A total of 1086 children aged 8–10 years were eligible for the study, of which 337 did not present the informed consent form signed by parents or were absent from school during data collection. The final response rate was therefore 69.0%, giving a total sample of 750 children. CPQ scores ranged from 0 to 68, with an average of 14.11 (SD = 10.95). Emotional well-being was the domain with largest variation (0–20), and the oral symptoms domain had the highest mean (5.14) (Table 1).
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Schoolchildren oral health related quality of life
Table 1. Descriptive distribution of overall and domainspecific CPQ scores (n = 750). Pelotas/2010. Number of items
Mean CPQ scores (SD)
Possible range
Range
25
14.11 (10.95)
0–100
0–68
5
5.14 (3.06)
0–20
0–15
5
2.65 (3.04)
0–20
0–17
5
3.35 (3.84)
0–20
0–20
10
2.98 (4.06)
0–40
0–26
Table 2. Sample distribution and mean CPQ score (n = 750). Pelotas/2010.
Variable Total CPQ Domains Oral symptoms Functional limitation Emotional well-being Social well-being
CPQ, Child Perceptions Questionnaire; SD, standard deviation.
Table 2 shows the distribution of the sample and the association of the independent variables with mean of CPQ score. The majority (75.8%) was white-skinned females (53.9%) and came from nuclear families (64.8%). Demographic and socioeconomic characteristics that were associated with oral health-related quality of life scores were skin color (P < 0.001), with non-white skin children presenting higher CPQ scores, maternal education (P < 0.001), with children whose mothers had less than 8 years of schooling reporting worst oral health-related quality of life, and family income, with children from low-income families presenting higher scores. Family structure (P = 0.003) and household crowding (P = 0.007) were also associated with CPQ: Children from non-nuclear families and from overcrowded housing reported impaired oral health-related quality of life, compared with their counterparts. In addition, children who reported dental fear and who had experienced dental pain in the last 6 months presented higher CPQ scores (P < 0.001). Associations between the clinical indicators derived from the dental screening and oral health-related quality of life scores are presented on Table 3. Self-reported dental trauma was shown to be associated with worst impact on oral health-related quality of life (P < 0.001), as well as experience of dental caries (P = 0.002) and the presence of decayed teeth in the moment of the dental examination (P < 0.001). Also, children with DPI higher than 5 (P = 0.002) and presenting
361
Sex Male Female Age 8 9 10 Skin color White Non-white Maternal schooling >8 years ≤8 years Familiar income 1 (R$ 1020–12,000) 2 (R$ 580–1019) 3 (R$ 0–580) Family structure Nuclear Non-nuclear Household crowding 1st (2–4) 2nd (5–6) 3rd (7–15) Dental fear No Yes Dental pain Absent Present
n (%)
Mean CPQ8–10 score (SD)
353 (47.07) 397 (53.93)
13.34 (10.31) 14.80 (11.46)
0.069
171 (22.80) 295 (39.33) 284 (37.87)
12.62 (9.91) 14.63 (11.81) 14.48 (10.57)
0.211
552 (75.82) 176 (24.18)
13.18 (10.38) 17.17 (12.36)
