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Social Science & Medicine 60 (2005) 1859–1868

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Variation and change in the meaning of oral health relatedquality of life: a ‘grounded’ systems approach

Jane Gregory, Barry Gibson, Peter G. Robinson�

Unit of Oral Health Services Research and Dental Public Health, Guy’s Kings and St Thomas’ Dental Institute, Room 202,

Denmark Hill Campus, Caldecot Road, Denmark Hill, London, SE5 9RW, UK

Available online 5 November 2004

Abstract

Changes in concepts of health and disease have led to increased interest in health related quality of life in medicine.

Quality of life measures tend to treat quality of life as a stable construct that can be measured externally. They do not

consider people’s differing expectations and assume that what quality of life means to people is stable over time. This

paper reports on a study which aimed to find out how measures of oral health related quality of life (OHRQoL) vary

between and change within individuals. Longitudinal semi-structured open-ended interviews were carried out with

twenty people with socially noticeable broken, decayed or missing teeth who were or were not seeking dental treatment.

The data were collected and analysed using the iterative processes of grounded systems theory based on Glaserian

(Theoretical Sensitivity, The Sociology Press, Mill Valley, CA, 1978) grounded theory and Luhmann’s (Social Systems,

Stanford University, Stanford, 1984) social systems theory. During the data analysis it emerged that participants’ were

adopting positions on seven dimensions of oral health relating to the positions that people would adopt with respect

norm, attribution, trust, accessibility, commodity, authenticity, and character. The core distinction that accommodated

people’s varying positions was that people constructed their own margins of relevance of oral health. The margins of

relevance indicated a variable from a hypothetical extreme of ‘super-relevant’ to the other extreme of ‘not relevant’. The

margins of relevance could shift, meaning that assessments of quality of life would vary. Oral health related quality of

life is therefore defined as the cyclical and self-renewing interaction between the relevance and impact of oral health in

everyday life.

r 2004 Elsevier Ltd. All rights reserved.

Keywords: Oral health; Quality of life; Response shift; Systems theory; UK

Introduction

This paper reports on a study of how measures of oral

health related quality of life (OHRQoL) vary between

and change within individuals. The study of changing

assessments entailed looking at changing meaning with-

e front matter r 2004 Elsevier Ltd. All rights reserve

cscimed.2004.08.039

ing author. Tel.: +44 0 114 27 17843; fax:

92.

ess: peter.g.robinson@sheffield.ac.uk

).

in the broad theoretical framework of Luhmann’s

(Luhmann, 1984) functional structural approach to

social systems.

The increased interest in health related quality of life

in medicine and public health parallels changes in

general quality of life. Issues of life quality have replaced

concerns of about survival. However, health related

quality of life remains dynamic and difficult to measure

(Allison, Locker, & Feine, 1997). What quality of life

means to people is central to understanding subjective

views and to establishing the validity of these measures

d.

ARTICLE IN PRESSJ. Gregory et al. / Social Science & Medicine 60 (2005) 1859–18681860

(Mallinson, 2002). If quality of life means different

things to different people and can change over time, it is

difficult to define and associations between clinical

status and quality of life can be weak or non-existent;

a phenomenon that has been described as the ‘paradox

of health’ (Albrecht & Devlieger, 1999; Barsky, 1988;

Sprangers & Schwartz, 1999).

Weak associations appear in numerous studies in

health related quality of life (Locker & Slade, 1994; Soe,

2000; Weitzenkamp et al., 2000; Cushing, Sheiham, &

Maizels, 1986; Locker, 1992, 1997; Rosenberg, Kaplan,

Senie, & Badner, 1988; Slade, 1998). Moreover, long-

itudinal research indicates that people can undergo

simultaneous improvement and deterioration in quality

of life (Slade, 1998). While explanations for such

anomalies arise from different disciplines, it has also

been suggested that they emerge from the differences

between health and disease, that they belong to different

dimensions of human experience (Locker & Slade,

1994).

Psychological explanations for change and adaptation

have focused on response shift. Based on (Golembiews-

ki, Billingsley, & Yeager’s, 1976) theory of alpha, beta

and gamma change, response shift is defined as changing

internal standards, values and the conceptualisation of

quality of life. The same processes contribute to

variations in the meaning of quality of life between

individuals. Response shift may present problems in

evaluating treatments or more clinically equivalent

outcomes (Allison et al., 1997; Sprangers & Schwartz,

1999) in studies such as randomised controlled trials.

Likewise, if quality of life instruments were to be used,

without the support of clinical data to assess need in

planning resource allocation, they may perpetuate

inequalities and condemn people to their social roles.

Response shift represents a significant advance in

approaches to assessments of quality of life. It is

nevertheless problematic because, unlike sociological

accounts, it does not consider the relationship between

the person and their environment (Bury, 1982).

Theoretical background

The suggestion by Locker and Slade (1994) that

health and disease are different domains of human

experience suggests that an approach to this problem

might be found within general systems theory (Von

Bertalanffy, 1968). One such theoretical perspective is

that of social systems theory (Luhmann, 1984). Luh-

mann’s theory is developed from a number of strands

including phenomenology, the Laws of Form (Spencer

Brown, 1969) and radical constructivism (von Glasers-

feld, 1984).

Health related quality of life measures are often

dominated by a functional role model, and assessed

through proxy measures which contain normative

assumptions about health as it relates to quality of life

(Higgs, Hyde, Wiggins, & Blane, 2003). Luhmann’s

constructivism marks a shift from structural functional-

ism (e.g., Parsons) to a functional structuralism. The

contingent nature of Luhmann’s use of function con-

trasts with traditional functionalism where social norms

and institutions are explained by their beneficial effects

on the reproduction and survival of society as a whole.

For Luhmann systems are primarily communication

systems, which do not evolve in any purposeful or

rational way (King & Thornhill, 2003), they may or may

not become functional in their interdependence with

other systems. The functional structural turn in Luh-

mann’s theory leads to the centrality of ‘emergence’ and

emergent meaning. Thus methods of grounded theory

could be used to look at assessments of quality of life;

especially, since the method proposed by Glaser (1978) is

based on the same criteria of ‘fit’ and ‘workability’ as the

functionalism of Luhmann. This reversal, of theoretical

approaches within modern ‘functionalism’ has yet to be

applied to assessments of quality of life.

This study developed a ‘grounded systems theory’

through the integration of the grounded theory and

systems theory. This framework implies that knowledge

is an emergent construction rather than a pre-existing

entity. Closely related to this is the fact that the

construction of categories and theories is a process of

two interacting levels of observation rather than the

discovery of what is in the ‘data’ as a pre-existing reality.

Put simply, there are the observations of the partici-

pants, and there are the secondary observations of the

researcher, each of which interact in the developing

theory. It follows that in grounded systems theory data

analysis is specifically concerned with communications

(or what people say) and how this is organised rather

than discovering ‘what is out there’ (Glaser, 1978). What

follows is an outline of the way grounded systems theory

departs from traditional grounded theory.

Open coding in grounded theory (Glaser & Strauss,

1967) was described as a process of categorisation; little

more was said about it in epistemological terms (Dey,

1999). In grounded systems theory open coding estab-

lishes the ‘indications’ people make (observations that

are articulated) and looks to see how these relate to one

another using a process of constant comparison. Bearing

this in mine, the goal in this study was to discover the

sorts of distinctions that operate in communications

about oral health and how this relates to quality of life.

This was not always easy, for example, what lies on the

other side of what someone was saying is not always

readily apparent. It was only through the constant

comparison of indications to other indications that

organising distinctions could emerge. Thus, where

grounded theory is principally concerned with the

discovery and emergence of the core category, systems

theory is concerned with the discovery and emergence of

ARTICLE IN PRESSJ. Gregory et al. / Social Science & Medicine 60 (2005) 1859–1868 1861

the core distinction; a distinction that can organise and

explain what people say rather than what they think or

feel. Classic grounded theory is organised around the

discovery of the core concerns of people and accounting

for these by finding an adequate conceptualisation. The

identification of the main concern is not only to explain

the variation in the data but is also the way that the

researcher strives to achieve ‘fit’ and ‘workability’ for the

theory. However, seeing the search for the core category

in this way does not recognise the problem of

intersubjective understanding, which emerged as part

of the crisis of representation in qualitative research

(Denzin and Lincoln, 1994). Systems theory is based on

the belief that true intersubjective understanding is

impossible. Combining grounded theory with systems

theory means there cannot be a search for the main

concern of participants. Instead, it must search for the

‘core distinction’ underlying the participants commu-

nications. In this way the ‘core distinction’ is a

construction of the observer. Most importantly it serves

to organise and explain the variation in what is observed

concerning change in the meaning oral health related

quality of life.

Rationale and aim

As inconsistencies between clinical and subjective

measures have resulted in claims of a ‘paradox of

health’, it is necessary to understand how individual and

environmental factors drive assessments of quality of life

beyond actual clinical status. To explore the relationship

between ill health and quality of life this project aimed

to find out how assessments of oral health related

quality of life (OHRQoL) vary between and change

within individuals. The study looked at changing

meaning within the broad theoretical framework of

Luhmann’s functional structural approach to social

systems.

Method

Purposive sampling was used to recruit 20 male and

female participants of different sex, ages and social

groups. Two groups of 10 participants were recruited

with similar clinical status but apparently differing

responses to that status. All participants had socially

visible decayed, missing or broken teeth as judged by a

lay person (a non-clinical researcher) from a social

distance. One group consisted of people planning to visit

the dentist whilst the other consisted of people not

seeking care. The first group were recruited through

dentists and snowball sampling. The second group were

recruited using a combination of advertisements in shop

windows and local publications and snowball sampling.

Ethical Approval was granted by King’s College

London Research Ethics Committee.

Each participant was interviewed individually on two

occasions. The interviews were semi-structured, open-

ended, lasted between one and two hours and were

audio-recorded. In the first interview participants were

asked about their daily lives, their challenges and hopes

for the future to obtain a feeling for their general

expectations and the context in which they talked about

oral health. Photographs of people with varying degrees

of oral health and disease were introduced during the

interview to stimulate observations without pre-struc-

turing the interview.

The second interview took place up to three months

later to see if the way participants talked about oral

health had changed. More directive prompts were used

including dental leaflets and artefacts such as dental

floss, mouthwash, a dental mirror and probe. Partici-

pants were asked what ‘quality of life’ meant to them

and how they thought it might relate to oral health.

The data were analysed according to the integration

of systems theory with the grounded theory method (See

theoretical background above). Initially transcripts were

coded in a similar way to substantive coding in

grounded theory. As coding progressed the constant

comparative method was used to ‘mark’ the variation in

what people and to explore how the emerging codes

related to each other. This process differed from

traditional grounded theory because it aimed to uncover

a series of distinctions underlying what was being said.

For example, people would often talk about teeth being

imperfect or too perfect. This group of communications

seemed to be evaluating the falseness or naturalness of

teeth and were eventually grouped under the term

‘naturalising’. When the category was examined in more

depth it emerged that participants were often adopting

opposing positions about the appearance of teeth.

Distinguishing positive and negative attributes appeared

to the researchers to indicate that they were adopting a

position and the category was eventually relabelled

‘positioning of authenticity’. The category therefore

related to anything said that addressed the authentic or

inauthentic nature of someone’s mouth.

By representing contrasting but not dichotomised

meanings, the dimensions contained ‘contradictions’ or

crossing perspectives that were subsequently coded

accordingly. The process was continuous as new

concepts emerged accounting for the distinctions people

were drawing. Of interest was how often people would

re-examine what they had previously said on each of the

dimensions so discovering that they held inconsistent

positions. Such occurrences would often trigger a change

in one or more positions as they tried to resolve the

observed inconsistency or contradiction.

Finally, a core distinction was constructed and it

helped organise and explain how what was said

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appeared to be organised as it changed and varied. As a

construction of the researchers this core distinction

operated at the second level of observation. The test for

the emerging theory was the degree to which this core

distinction fitted and worked in accounting for the

process of variation and change in meaning.

Results

The meaning of oral health

During the data analysis it emerged that participants’

adopted positions on seven different dimensions of the

meaning of oral health. Fig. 1 shows each dimension as a

range of positions along a common theme. In terms of

systems theory, the adoption of a position is akin to

making an indication by observing and uttering some-

thing. For example, most people talked about dentistry

as a commodity either embracing or rejecting the notion

that ‘health’ or ‘changed appearance’ could be ‘bought’.

In observing a white and possibly cosmetically enhanced

smile, Margaret (who was seeking treatment) accepted

Positioning of the norm

Health

Positioning of attribution

Internal

Positioning of dentistry

Trust

Positioning of accessibility

Choice

Positioning of commodity

Embracing

Positioning of authenticity

Natural

Positioning of character

Admiring

Fig. 1. The symbolic dimensions of const

the concept of a ‘bought’ mouth and aspired to have

one:

‘‘Yeah very nice, that’s it. Is that veneers? Yeah

they’re lovely. I’d like to have white teeth like that. I

think they’re lovely, lovely teeth.’’ (Margaret, Em-

ployed within the home, age 48, 4/4/01).

In contrast, dentistry was seen by Fred (not seeking

dental care) as an exploitative product to be rejected:

‘‘I’m amazed at the fortunes people spend on their

mouthsyI mean we all want to keep our beautiful

good looks or whatever and teeth are part of that and

we can be very exploited for that fact. I mean—you

know the advertising in woman’s magazines, so people

have got to feel that ‘my teeth have got to look like

that.’’ (Fred, English lecturer, age 67, 19/10/01)

Of importance was that it was not simply the

commodified aspect of oral health that was being used

to indicate something but that the person was adopting

a position on this dimension. The dimension was

therefore conceptualised as a ‘Positioning of commodity’

disease

external

distrust

no choice

rejecting

unnatural

denigrating

ructing the relevance of oral health.

ARTICLE IN PRESSJ. Gregory et al. / Social Science & Medicine 60 (2005) 1859–1868 1863

where ‘Positioning’ referred to the specific selection of

the meaning that the particular dimension had at that

point in time.

Some people perceived that oral health resources,

including dentists and products could be purchased in

order to maintain a healthy mouth. Whether these

resources were accessible depended on factors including

economic resources, where people lived, knowledge and

the confidence to request help if needed. Positioning of

accessibility was therefore a matter of degree between

completely accessible to completely impossible to

obtain. In observing a picture of a man with mal-

aligned and diseased teeth and gums, Sally who was

seeking dental care remarked:

‘‘We have dentists, and we have access to dentists.

Products, toothpastes, toothbrushes. There is no

need for anybody to have teeth like that in this

countryymost people can get some form of Na-

tional Health dentist (Sally, Administrator, age 38, 6/

5/01).

Although ‘accessibility’ suggests a material constraint,

it often related to whether people felt that they were

capable of gaining access to oral health. Accordingly,

resources had to be available and obtainable. Some had

chosen to give up altogether as a result of their lack of

choice:

‘‘I went to one and, ah, they couldn’t put me on their

books so I thought ‘Ah bollocks to it’ and don’t

botheryThey’re all private now. Ones that aren’t—

they’re fully booked upy’’ (Boots, Unemployed, age

29, 25/10/01)

Further dimensions related to positions adopted with

respect to norm, attribution, authenticity, character and

dentistry. Positioning of the norm concerned the experi-

ence of disease as the norm versus the experience of

health. Positioning of attribution referred to whether or

not attributions concerning the causes of oral health or

disease were due to either internal or external factors.

Positioning of authenticity concerned positive or negative

observations around the ‘naturalness’ of the teeth and its

relationship with the appearance of the mouth. Position-

ing of character related to both admiring healthy teeth

and associating them with goodness and attractiveness.

In contrast, the same distinction could relate to a person

being viewed as vain, effeminate and/or insincere:

‘‘y he’s a tart isn’t he? Aye?—you can see that

straight away can’t you. Way he’s smiling, the false

smile...I wouldn’t entertain the geezer.’’ (Boots,

Unemployed, age 29, not seeking care, 26/11/00).

Positions adopted with respect to dentistry (Position-

ing of dentistry) were concerned with articulating the

degree of trust or distrust in the dental profession and its

products. Trust symbolised the safety, reliability, ex-

pertise and efficacy of dental professionals and their

products.

Given the symbolic meaning of oral health along these

seven dimensions what remained was to see if there was

a core distinction at the heart of these communications.

In the following example Helen, who had had a broken

tooth crowned, linked the way she felt about her

physical health and appearance with more than a few

aspects of her life:

‘‘If you feel that whatever it—whatever characteristic

about you is affecting your reception by other people

and you are isolated because of that—or you feel

isolated because of thatythat has an adverse effect

on your quality of life—which in turn—has a

devastating effect on your self-esteem. And having a

low self-esteem affects your life chances. Becauseyif

you have a really low self-esteem—often there is a

mindset that—I can’t do that—I wouldn’t be able to

do that’’ (Helen, Teaching assistant, age 46, 20/10/01).

The broad indication of this statement demonstrated

the huge scope of oral health to affect her everyday life.

Such communications contrasted sharply with a sig-

nificant body of statements that seemed to ‘negate’ the

significance of oral health. Geoff, who was not seeking

treatment negated the scope of impact of broken and

decayed teeth:

‘‘I’ve never worried about the looks of them. I’ve

never been terribly concerned about what people

think of me from a looks point of view.’’ (Geoff,

Lorry driver, age 57, 24/10/00).

Barry, who had a missing front incisor, used another

health problem as an analogy to demonstrate that there

was no reason why he should have to take notice of

others opinions or return to the dentist :

‘‘I mean I suffer through eczema. Covered in it. And

yet it don’t bother me. I don’t have to look at myself.

It’s other people it bothers’’ (Barry, Lorry driver, age

55, 27/11/00).

It was the contrast between statements like these that

led to the emergence of the core distinction that oral

health was either relevant to all aspects of everyday life

(super relevance) in contrast to being less relevant (low

relevance). The position adopted on each dimension

always said something about the relevance of oral

health. It was suggested that the relevance/irrelevance

distinction was a variable, which changed in response to

the indications the person made. We therefore began to

talk of ‘the margins of relevance’ (a second-order

construct of the research process that was unobserved

from the perspective of the participants). As a latent

variable it was considered to be dependent, always in

ARTICLE IN PRESSJ. Gregory et al. / Social Science & Medicine 60 (2005) 1859–18681864

some way related to first-order indications being made

by participants. When discussing changes in the margins

of relevance we are therefore talking about changes in

this second-order variable. There were no instances of

first-order references to relevance where a participant

directly stated that an issue was or was not relevant, yet

the variable both fits and works and can explain the

underlying changes in how people talked about oral

health. The margins of relevance are therefore about the

recursive interplay of these first and second-order

inferences whereby the participant marks what is

relevant and the researcher names the process.

Contradictions, stabilisations and changes in the relevance

of oral health

Not all positions adopted on each dimension were

necessarily compatible. People were often confronted

with contradictions. These were not contradictions in

the same form of ‘mistakes’ (Temple, 2001) but equally

valid, yet conflicting, indications. The interplay of the

different positions on the meaning of oral health implied

that a continual and recursive change could occur in the

margins of relevance. In addition it suggested that the

process of change was about evaluations concerning the

meaning of oral health. What subsequently emerged

during data analysis was that contradictions could lead

to both stabilisations and/or changes in the margins of

relevance (termed ‘reality checks’ or ‘catalysts for

change’, respectively). It became critical to try and

assess just what people where doing when they where

confronting such alternative positions.

Reality checks in the margins of relevance

Jason’s communications had indicated that his oral

health had low relevance: ‘‘not a priority’’. When he

compared his teeth to those in a photograph he

recognised that teeth could be much more relevant:

‘‘Yeah, set of perfect teeth, absolutely perfectybit

depressingly perfect really. I think you look at those

and wish that yours were absolutely straight.’’

(Jason, IT technician, age 30, 28/5/01).

Conflicts in meaning could be balanced so stabilising

the boundaries of relevance. For example, treatments to

improve the appearance of the mouth might be

desirable, but these desires could be balanced with

indications about the ‘naturalness’ of teeth and anxiety

about the dentist. In the following example Maureen

(seeking treatment) drew a balance between appearance,

which was relevant to her, and the long-term condition

of her teeth:

‘‘There’s a limit to what I would do—to look, to have

perfect teethyI might have had beauty for a few

years but I can’t believe those two teeth wouldn’t be

weakened in some way.’’ (Maureen, Occupational

therapist, age 48, 4/5/01)

These justifications acted as ‘reality checks’; stabilis-

ing margins of relevance, defending the status quo.

These stabilisation’s emerged as a result of the recursive

interaction between first and second order observations.

The reality check in this example contrasts sharply with

Sally who had her teeth repaired and cosmetically

enhanced. The work had cost very large sums of money

and she subsequently went on to focus on even more

possibilities for her teeth:

‘‘I’d have done moreynow, if I was having them

done now, I would probably go that one step

furthery’’ (Sally, Administrator, age 38, 11/10.01).

Catalysts for change

Stabilisation in the relevance of oral health contrasted

with examples where relevance increased or decreased.

Sandra’s oral health was relevant because it produced a

feeling of comfort and she needed to have a clean mouth

(Positioning of the norm). Although considering having

her front teeth repaired, she remained anxious about

going to the dentist (Positioning of dentistry). At the

follow-up interview because she was looking for a new

job, the way she talked indicated that her appearance

had changed to become more relevant:

‘‘Sometimes I’m going into the bathroom and I’m

doing my makeup or something and I’ll catch a

glimpse of my mouth in the mirror and sometimes I

won’t look again cause I think ‘no, not even going to

go there’ and I’ll go out. And then other times I think

‘oh it’s really bad, it’s awful’yYou know, so I sort of

like put a denial sheet over it really so I can just be

myself. If I didn’t do that maybe I would be more

conscious or I wouldn’t smile as much or wouldn’t be

myself but I smile a lot.’’ (Sandra, Student, age 35,

18/10/01).

Sandra’s ‘denial sheet’ was her way of acknowledging

that she had denied the relevance of her oral health.

The emergence of this conflict in the second interview

acted as a catalyst for change. The observation that

oral health could have alternate possibilities for her

often prompted further comments, which in turn

would lead to changes in the margins of relevance.

Relevance could therefore increase. Having finally

succeeded in having his tooth repaired, Gary noted

that once satisfied it was easy to focus on other

faults: ‘‘Happier with it now and I suppose start

picking holes in the other ones’’ (Gary, 10/11/01).

It also emerged that taking part in the study could

ARTICLE IN PRESSJ. Gregory et al. / Social Science & Medicine 60 (2005) 1859–1868 1865

‘trigger’ changes in the relevance of oral health as in the

example of Maureen:

‘‘I look at peoples teeth all the time now, well the

people that I’ve noticed since the last interview,

because I’ve been noticing more’’ (Maureen, 12/10/

01).

Maureen’s margins of relevance had increased,

supported by the pressure to look good. The availability

of commodities was subsequently used to further justify

extensive treatment:

‘‘We have these facilities—why not? We all use

potions and lotions, surgery is the next step up.’’

(Sally, Administrator, age 38, 11/10.01).

The way in which the various dimensions related to

aspects of everyday life had important consequences for

the relevance of oral health. In the interviews people

often recounted how the experience of pain or social

pressure impressed the significance of their oral health.

This contrasted with other factors, such as accessibility,

which would often constrain relevance so that some

people were resigned to having poor oral health. Geoff

indicated that he could no longer eat many foods and

suffered intermittent pain. He failed to find a dentist and

had given up trying:

‘‘I really wish they did fit like if only it makes life a bit

easier when it comes to eating—cause I’ve only got

about two teeth that actually meet now. They’re all

pretty rotten—really bad and I’d have to go to the

dentist—but I think I’m past caring now.’’ (Geoff,

Lorry driver, age 57, 24/10/00).

Later he continued to indicate concern about his oral

health:

‘‘Pity you haven’t got a magic wand, give me some

nice pearlies’’ (Geoff, Lorry driver, age 57, 24/10/00).

Alternatively, Peter indicated a stoic acceptance of

declining oral and general health, to the extent that it

held little relevance to him: ‘‘I’m 53 like—going down-

hill rapidly like. Still got me sense of humour at times.

But, ah, that’s me—just carry on’’ (Peter, Unemployed,

age 53, 19/10/00). Other participants dismissed the

relevance of their teeth in this manner. Often it was

explained that the cause of problems lay in the hands of

the dentist, but Dentistry was no longer to be trusted to

rectify the damage. Some participants concluded that it

was best to give up: ‘‘I’ll just let ‘em rot’’ (Barry, Lorry

driver, age 55, 27/11/00).

The horizons of possibilities

The sampling process naturally encouraged a broad

range of discussions about oral health. What became

apparent to the researchers, however, was that some

people could not see the same scope of possibilities for

the meaning of oral health that others could. We decided

that this scope reflected something about the relative

freedom people had to think about the meaning of oral

health. The term used to account for this observation

was the ‘horizon of possible meanings’ that were

available to the participant. ‘The horizon of possibilities’

was borrowed from Luhmann (1984) and used in this

context referred to the range of potential meaning that

oral health could have. A very particular horizon of

possibilities was reflected in distinctions made by Fred,

who in the process of retiring from work, noted that oral

health was difficult to obtain for his age group:

‘‘ypensioners are not given any help at all unless

they’re poverty strickenyAnd once people are over

sixty-five they could suffer a lot of dental ill health

because of lack of money to pay for it’’ (Fred, Semi-

retired English lecturer, age 67,19/10/01).

It should be noted that the horizon of possibilities

indicated in this statement shows little room for change.

In contrast Margaret’s statement displays a very

different horizon:

‘‘I think teeth are very important. You’ve got to

make yourself look lovely and nice as much as you

can, especially as you are growing olderyI’m not

going to grow old gracefully. I shall fight it all the

way’’ (Margaret, Employed within the home, age 48,

4/4/01).

Between the first and second interviews (perhaps as a

result of a severe illness in the family) the possibilities for

her oral health changed from focussing on health to the

problem of disease:

‘‘Only toothache, if you’ve got pain or—that would

stop your life wouldn’t ityAnd when everything’s

like that you know—trouble with your teeth and

disease and things like that. Quality of life is to be

free. Free of pain and—you know’’ (Margaret,

Employed within the home, age 48, 30/10/01).

Discussion

The results of this study indicate that variation in

meaning does exist in oral health related quality of life

and this holds a number of implications for the

applications of such measures. Potential applications

of quality of life indicators include assessments of the

effectiveness and efficiency of health care and the

monitoring of individual patient care (Robinson, Hig-

ginson, & Carr, 2002). If quality of life assessments are

used to evaluate treatments, in longitudinal studies such

as randomised controlled trials, then the methods of

ARTICLE IN PRESSJ. Gregory et al. / Social Science & Medicine 60 (2005) 1859–18681866

assessment must be constant over time (Awad, Locker,

Korner-Bitensky, & Feine, 2000).

What needs to be considered is that the way people

feel about their quality of life does not develop in

isolation from their existing expectations (that constrain

what is relevant) as well as the environment in which the

margins of relevance are constructed. These data

demonstrate that the meaning of quality of life changes

over time; that response shift occurs in relation to

quality of life. These changes occur partly in response to

treatment and partly in relation to the recursive nature

of relevance coupled with the everyday environment of

the person. Quality of life measures therefore need to

take these factors into account.

While an alternative theoretical and methodological

framework has been used, this study provides indica-

tions concerning how response shift occurs with respect

to oral health. The findings can be aligned with the

response shift model (Sprangers & Schwartz, 1999).

Changes in the margins of relevance can be seen as beta

change, (changes in internal standards) whereas changes

in the relevance of dimensions can be seen as gamma

change, (changes in values and reconceptualisations of

quality of life). Mechanisms which have been related to

response shift such as social comparison (Festinger,

1954) also emerged and the general process of con-

structing the margins of relevance was also found to be

akin to adaptation theory (Helson, 1964). The interplay

of the seven dimensions articulated how the meaning of

oral health could vary between and within individuals.

Each of the dimensions covers key aspects of oral

health, some of which have not yet been considered in

relation to OHRQoL. For example, problems of access

to dental services demonstrate the symbolic importance

of accessibility as a central and contemporary problem

for oral health systems. Some participants in this study

were unable to find a dentist and this affected the way

they viewed their oral health. Structural functional

theories of quality of life would find such statements

problematic since these approaches focus on how the

individual organism ‘functions’ within the wider social

structure. The shift to the functional structuralism of

Luhmann (1984) however reverses the relationship. In

this broad theoretical context people are part of the

environment of social systems and any widespread

concern with accessibility is likely to become a problem

to be processed as a part of oral health systems. How

exactly this happens is one of the core problems of

Luhmann’s (1984) approach. In addition to this access

reflects over and above health and disease, control,

autonomy, (as well as pleasure and self-realisation)

(Higgs et al., 2003) all of which are part of general

quality of life. Accessibility in some form or other must

therefore be included in the dynamism of OHRQoL. It

also relates to the importance of trust in dentists and the

associated products of ‘dentistry’.

Trust in dentistry, dentists and dental products

formed a major symbolic dimension for communica-

tions about oral health related quality of life. As an issue

it relates to the nature of dental anxiety and whilst there

is substantial body of work on it, distrust is also

widespread (Locker, Liddell, & Shapiro, 1999; Newton

et al., 2001). The difference between apparently rational,

public assessments of trust expected from professionals

and the private assessments of trust and distrust that are

couched in anxiety is apparent in relatively recent HIV

scares in dentistry (Thorogood, 1995). The data in this

study suggest that distrust has a part to play in the

relevance of oral health and also indicates something

about the importance of trust as a core symbolic media

of health systems in general (Gilbert, 1998).

Research in oral health has not considered oral health

as a ‘commodity’ can impact on OHRQoL. Bauman

(1998) has argued that it is in the process of consump-

tion that individuals are now created and where the key

aspects of quality of life can be found (Higgs et al.,

2003). Commodity, and the ability to consume, is

strongly associated with social inclusion, with an

inability to participate linked to the ‘failed consumer’

(Bauman, 1998). Our data indicate that this is a

fundamental dimension to the meaning of OHRQoL.

Visible oral health and disease were used to judge a

person’s character in contrasting ways. Good oral health

could be used to denigrate someone’s character which

contrasts with existing research which has demonstrated

that people are judged negatively by the appearance of

their teeth ( Shaw, Rees, Dawe, & Charles, 1985, Shaw

& Humphreys, 1982). It followed that Positioning of

attribution echoes Rotter’s (1992) locus of control and

the effects of self-efficacy demonstrated in Antonovsky’s

(1996) salutogenic model of health. Finally, a wide range

of oral statuses can be normalised (Positioning of the

norm) something which was previously discussed with

reference to access (Gibson, Drennan, Hanna, & Free-

man, 2000).

These results indicate the broad nature and scope of

the relationship between dental status and quality of life.

The approach adopted differs from previous approaches

because it uses the modern functional structuralism of

Luhmann. The notion of relevance at the core of this

theory of oral health related quality of life resonates

with debates which posit a ‘needs satisfaction’ approach

(Higgs et al., 2003). This involves a shift away from

seeing ‘function’ in terms of whether something can be

accomplished to function in terms of why one might

want to accomplish something. A particular function

therefore only becomes a need if it means something to

the person. The meaning something has for someone can

of course be unobserved and latent and this might

particularly be the case with aspects of oral health which

relate to appearance (Newton, Prabhu, & Robinson,

2003).

ARTICLE IN PRESSJ. Gregory et al. / Social Science & Medicine 60 (2005) 1859–1868 1867

The recursive nature of the margins of relevance

between two modes of observation is very similar to

existing work which looks at the impact of oral health

on everyday life (Soe, 2000; Cushing, Sheiham, &

Maizels, 1986; Locker, 1997, 1992; Locker & Slade,

1994; Slade, 1998). In this work the impact of oral health

on the quality of life emerges from reflections on

problems with individual components of everyday life.

Current measures of OHRQoL are therefore based on a

similar recursive interplay. The results of this study

suggest that this work on OHRQoL could be extended

to include some measure of the relevance of oral health.

OHRQoL should therefore be defined as the cyclical and

self-renewing interaction between the relevance and

impact of oral health in everyday life.

Conceptualising the meaning of OHRQoL through

impact and relevance allows the health/disease dichot-

omy, which produces apparent paradoxes in indicators

of quality of life, to be unravelled. If health and disease

belong to different dimensions of human experience

(Locker & Slade, 1994), paradoxes occur when disease is

assumed by researchers to cause an impact. Relevance is

possibly the intervening variable mediating between

disease and impact. The data demonstrated many

instances where people were aware of their oral health

problems but implied that they were not of consequence

in their everyday lives.

Furthermore, as this study is situated within social

systems theory, the suggestion that there is no direct

casual link between bodily disease and psychological

impact can be made. Aspects of disease, which relate to

the body, and impact, which relates to psychic systems,

can trigger, but not determine, effects in each other

(Luhmann, 1984; Maturana & Varela, 1992). In this

scheme the mind and body are designated as separate

but interactively coupled systems and this provides

interesting possibilities for the theorising of embodiment

(Mingers, 1996). The body, as environment to the mind,

can be included in the guiding and constraining

dimensions, ‘‘selves act in ways that choose their bodies,

but bodies also create the selves who act’’ (Frank, 1995,

p. 40). If oral health is of low relevance there may be no

impact at all or at least not within the context of

everyday life.

Conclusion

These data reveal that the meaning of oral health

varies between people and changes over time and so

demonstrate the existence of response shift in relation to

quality of life. Such variation and change emerges

through OHRQoL as the recursive relationship between

impact and relevance, the individual and the social

structure. The idea of relevance in OHRQoL has not

been discussed before and some of the seven symbolic

dimensions of oral health have never been included in

measures of OHRQoL. We suggest that OHRQoL

could be reconceptualised as the cyclical and self-

renewing interaction between the relevance and impact

of oral health in everyday life. An inherent characteristic

of this process is that the margins of relevance differ

between people and change over time. These findings do

not contradict earlier approaches to OHRQoL but

extend the importance of measuring impacts by adding

further symbolic dimensions and arguing for some

assessment of relevance.

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