Community Dent Oral Epidemiol 2001; 29: 99–106 Copyright C Munksgaard 2001Printed in Denmark . All rights reserved

ISSN 0301-5661

Gustavo D. Cruz1, Diana L. Galvis1,Mimi Kim2, Racquel Z. Le-Geros1,Self-perceived oral health amongSu-Yan L. Barrow1, Mary Tavares3 andRima Bachiman1

1Minority Oral Health Research Center atthree subgroups of Asian-New York University College of Dentistry,2New York University School of Medicine,Department of Environmental Medicine, NewAmericans in New York City: York, NY and 3Forsyth Dental Center, Boston,MA, USA

a preliminary studyCruz GD, Galvis DL, Kim M, Le-Geros RZ, Barrow S-YL, Tavares M, BachimanR: Self-perceived oral health among three subgroups of Asian-Americans in NewYork City: a preliminary study. Community Dent Oral Epidemiol 2001; 29:99–106. C Munksgaard, 2001

Abstract – Objectives: The aim of this preliminary study was to compare the per-ception of oral health among subgroups of Asian-American residents of New YorkCity, USA. Methods: A close-ended questionnaire was administered to 255 Chi-nese, 134 Indian and 84 Pakistani adults, aged 18–65 years, during 1994–95. Acomprehensive dental and oral examination was also performed. The associa-tions of demographic and oral health variables with perceived oral health wereevaluated using multivariate ordinal regression models. Results: When data wereanalyzed in a multivariate context, only ethnicity and income were significant pre-dictors of perceived oral health, after adjusting for DMFT. The within-group mul-tivariate analysis of the three ethnic subgroups’ results were as follows: Amongthe Chinese there were no significant predictors, only income was strongly sug-gestive; among the Indians, number of missing teeth and number of years in the

Key words: Asian-Americans; ethnicity;USA were significant predictors; and within the Pakistani group, DMFT was the minorities; oral health; self-perceived oralonly significant predictor. Conclusions: Results suggest that there are ethnic differ- healthences in the perception of oral health status even after adjusting for clinical vari-

Gustavo D. Cruz, New York Universityables as well as for demographic variables in this particular group of Asian-Ameri- College of Dentistry, 345 East 24th Street,can residents of New York City. Predictors associated with the perception of oral Room 806, New York, New York 10010, USA

e-mail: gdc1/is6.nyu.eduhealth are different for each ethnic group. When designing oral health promotionactivities to diverse ethnic groups, the cultural characteristics of each subgroup Submitted 3 March 1999; accepted 30 Mayshould be considered. 2000

In New York City there has been a continuousincrease in Asian immigration, from an annualaverage of 16 900 in the 1970s to an annual averageof 29 400 in the early 1990s (1). The term Asian-American encompasses people with many differentcultural and religious backgrounds, as well as a va-riety of languages. However, this classification isnot usually defined in most health studies and re-ports. The term Asian/Pacific Islanders, regularlyused in the USA for research purposes, covers alarge number of cultures with at least 32 differentlinguistic groups, and a large number of individ-

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uals who differ greatly in terms of religion, life-style, diet and health behaviors (2).

The Research Center for Minority Oral Health(RRCMOH) at the New York University College ofDentistry (NYUCD), a collaboration between NY-UCD and the Forsyth Dental Center in Boston, wasestablished in 1992 funded by the National Insti-tute of Dental and Craniofacial Research (NIDCR)of the National Institute of Health (NIH). One ofthe principal objectives of the RRCMOH is to im-prove the oral health of USA minorities throughresearch. One of the major research projects of the

Cruz et al.

RRCMOH is conducting several epidemiologicalstudies on previously under-represented racial andethnic minorities residing in New York City (NYC).During Phase 1, this Center conducted a compre-hensive epidemiological study of the oral healthstatus of three Asian-American subgroups: Chi-nese, Indian and Pakistani. The results presentedhere are based on secondary analysis performed onthat data, collected during 1994–1995.

Previous research data suggest that althoughmost oral health disparities may be the result ofsocioeconomic disadvantages, an additional con-tributing factor is the racial/ethnic background ofthe diverse groups (3, 4). Cultural differences in-fluencing health behaviors and beliefs have beendocumented (5). Perception of oral health is a con-cept associated with dental services utilization, aswell as actual clinical status (5, 6). Moreover, it hasbeen asserted that people define their oral healthproblems; they don’t just experience them (7). Inorder to appropriately plan oral health care (in-cluding its promotion and outreach programs) fordiverse communities, we must understand the de-terminants of their concepts of oral health. Percep-tion of oral health may not only influence careseeking behaviors but the acceptance of oral healthpromotion activities.

The concept of need in health care is usually de-termined by perceptions of health and perceivedneed for care. Perceptions of oral health depend onthe understanding by the individual of what ‘‘nor-mal’’ oral health is, and the specific symptoms heor she may experience (8). An individual’s conceptof health is not only determined by cultural valuesbut by past experiences with the health care system(4, 9). Furthermore, lifelong economic and healthconditions as well as psychosocial well-being of di-verse populations have differential cumulative ef-fects on oral health and oral health related qualityof life (10). All of these concepts, experiences andbeliefs are filtered by the cultural norms and valuesheld by the different groups.

Perception of oral health and need have beenfound to influence care seeking behaviors (11, 12).Moreover, care seeking behaviors have been shownto vary according to race and ethnicity in the USA(13) and in other countries (14). Most of the studiesconducted on perception of oral health have beenconducted in older populations (15–20). Scarce datais available regarding the relationship of race, cul-ture and ethnicity to perceptions of oral health (6,21–23). In a recent study of perception of oralhealth in a diverse sample in the USA, it was found

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that ethnicity was one of the most important pre-dictors, along with education, of perceived generalhealth status, being edentulous or not having apartial denture, having no oral pain, fewer oralsymptoms, and having one or more dental visits(23). Prior to this study, no comprehensive oralhealth study had been conducted to assess the oralhealth status or the perception of oral health ofAsian-American residents of New York City.

The objectives of this study were: 1) to determinethe relationship between ethnicity, socio-demogra-phic factors, and clinical variables with perceptionof oral health among the combined group of Asian-Americans that were participants of the study, and2) to compare the determinants of perception oforal health between the three Asian-American sub-groups: Chinese, Indian and Pakistani.

Subjects and methods

Subjects from the following three ethnic groups:Chinese, Indian and Pakistani, who were living inNew York City during 1994–95 were recruitedthrough community outreach activities performedby the RRCMOH. The primary recruitment siteswere houses of worship and community-based or-ganizations, social and health centers that serveprimarily Asian-Americans in New York City,USA.

A self-administered, close-ended questionnairewas administered to the participants. When neces-sary, trained bilingual interviewers were used. Thesurvey instrument was translated into Chinese.The Chinese survey was the only one translatedbecause in New York City there is a large popula-tion of ethnic Chinese who do not speak English.This was not the case for the Indians and Paki-stanis, who were largely bilingual. In addition, cal-ibrated examiners performed a comprehensivedental and oral examination the same day as thesurvey. Measures of coronal caries were obtainedduring field examinations using visual and tactiletechniques, by trained and calibrated examiners,according to NIDCR criteria. Intraclass correlationcoefficients were calculated to assess intra- and in-ter-examiner reliability. The scores for inter-exam-iner reliability ranged between 0.88 and 0.99, andthe intra-examiner scores between 0.96 and 0.99.

All the examinations were recorded by trainedpersonnel in specially designed forms. The re-search team comprised NYUCD faculty and stu-dents. The clinical variables included in the anal-ysis were the following: the DMFT index (mean

Self-perceived oral health among Asian-Americans

number of decayed, missing and filled teeth pergroup), the percentage of decayed teeth and thenumber of missing teeth. An Institutional ReviewBoard (IRB) approval from New York Universitywas obtained prior to the inception of the study.

The single item assessing perceived oral healthwas asked as follows: How healthy would you sayyour teeth and mouth are? The possible responseswere: 1. Very healthy, I have no problems; 2. Okay,but I have some problems; 3. I have pain and dis-comfort; and 4. I feel that I need treatment badly.Face validity was established through consultationwith several faculty members of NYUCD and a fa-culty member of another educational institution inNYC. Content validity was obtained through focusgroups comprised of dental students and facultymembers of NYUCD who were also members ofthe targeted communities.

A ‘‘snowball sampling’’ technique (24) was em-ployed in order to obtain the individuals from thetargeted groups. Working within the framework ofcommunity centers, churches and local health cen-ters this strategy relies on initial study volunteers toprovide access to other members of their group orcommunity. For each subgroup, areas of NYC thathad the highest concentration of targeted individ-uals were identified. Working with members of thecommunity at NYUCD, community leaders wereidentified, who in turn helped to gain access to thecommunity centers. The participants were invited toparticipate in ‘‘oral health fairs’’ conducted at the re-spective community centers. Recruitment strategiesincluded flyer distribution, advertisements in localpapers and word of mouth initiated by the com-munity leaders. Refusals to participate in the studywere minimal since all of the advertisements for thefairs clearly indicated their purpose. The sample sizeof this study was based on 255 Chinese, 134 Indianand 85 Pakistani adults (aged 18–65 years) who hadcompleted both the survey and the clinical examina-tion during 1994–95.

Statistical methods

Demographic and clinical characteristics betweenethnic groups were compared using the Kruskall-Wallis test for continuous variables, and the chi-square test for categorical variables. Pairwise com-parisons between ethnic groups for the continuousvariables were performed using Fisher’s LeastSignificant Difference method on the rank trans-formed data.

Because the perceived oral health variable is an

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ordinal variable with four ordered categories, ordi-nal regression models (25), which are an extensionof the logistic regression model for binary responsedata, were used to evaluate the bivariate and multi-variate associations of sociodemographic and clin-ical variables with perceived oral health. The logitof the cumulative response probabilities of the per-ceived oral health response categories were mod-eled as a linear function of the covariates using theSAS software procedure, PROC LOGISTIC (26).Cumulative odds ratios and corresponding 95%confidence intervals were computed for each pre-dictor variable. Because lower categories of the re-sponse variable correspond to better perceptions oforal health, cumulative odds ratios greater than 1imply increased odds of better perception of oralhealth for that stratum of the predictor variable rel-ative to the reference stratum. Conversely, a cumu-lative odds ratio less than 1 implies decreased oddsof better perception of oral health compared withthe baseline stratum. For continuous predictorvariables, cumulative odds ratios were computedby categorizing the variable into tertiles based onthe combined study population. Tests for lineartrend on these variables were also performed. Theincome variable was analyzed as an ordinal cate-gorical variable.

For the multivariate analyses, the final modelwas determined using a backward elimination ap-proach including all demographic and clinical vari-ables as the initial model. At each stage of the mod-el fitting procedure, the least significant variablewhich did not satisfy the criterion of P,0.10 wasremoved from the model. The variable DMFT wasretained at each stage regardless of statistical signi-ficance, however, to adjust for the effect of oralhealth status on perception of oral health. The pre-dictive ability of the final model, as measured bythe rank correlation of predicted probabilities of re-sponse from the model and the observed response,was assessed using the c-statistic (27).

Statistical analyses were first performed on thecombined study population to evaluate overall dif-ferences in perceived oral health between ethnicgroups. Analyses were also performed separatelyfor each ethnic group to identify group specific pre-dictors of perceived oral health. The findings fromthe subgroup analyses were confirmed by evalu-ating the significance of interaction terms betweenethnicity and relevant predictor variables in thecombined model. Results from fitting the interac-tion effects are not presented because they did notdiffer from the subgroup analyses.

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Results

Results comparing the demographic characteristicsbetween ethnic groups are summarized in Table 1.Significant differences in the distribution of age,level of education, income, and number of yearsresiding in the US were observed between groups.Specifically, the Chinese and Indian groups were

Table 1. Demographic and clinical characteristics by ethnic group

Variable Chinese Indian Pakistani P-value

Agen 254 133 84 0.01*Mean 49.78 46.53 40.43Median 48 47 39Range 19–92 18–77 18–70

Gender n (%)Male 107 (42%) 66 (49%) 44 (52%) 0.19†

Female 148 (58%) 68 (51%) 41 (48%)

Education n (%)Æ12 years 128 (82%) 42 (34%) 25 (31%) 0.001†

.12 years 28 (18%) 81 (66%) 56 (69%)

Income n (%),20,000 116 (81%) 52 (44%) 19 (28%) 0.001†

Ø20,000 18 (13%) 48 (41%) 33 (48%)Don’t know/refused to answer 9 (6%) 17 (15%) 17 (25%)

Number of years in USn 245 122 80 0.03*Mean 7.64 9.11 9.70Median 5 6 10Range 0–45 0–34 0–35

DMFTn 255 134 85 0.05*Mean 6.42 5.59 4.91Median 5 4 3Range 0–28 0–22 0–22

%D/DMFTn 226 114 67 0.28*Mean 24.39 29.65 33.50Median 11 17 13Range 0–100 0–100 0–100

Missing teethn 255 134 85 0.0001*Mean 2.86 2.47 0.82Median 1 1 0Range 0–26 0–22 0–16

Perceived dental health‡

1 7 (3%) 25 (20%) 21 (28%) 0.001†

2 92 (40%) 64 (52%) 45 (59%)3 76 (33%) 21 (17%) 3 (4%)4 56 (24%) 14 (11%) 7 (9%)

* Kruskall-Wallis test.† Chi-square test.‡ 1ΩVery healthy, I have no problems; 2ΩOkay, but I have some problems; 3ΩI have pain and discomfort; 4ΩI feel that I need

treatment badly.

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older than the Pakistani. A smaller proportion ofthe Chinese reported more than 12 years of educa-tion and an annual income of at least $20 000 thandid either of the other ethnic groups. The Chinesehad also resided in the US for a shorter length oftime than the Pakistani. The groups did not differwith respect to gender distribution.

Ethnic differences in clinical characteristics were

Self-perceived oral health among Asian-Americans

Table 2. Combined group analysis

Bivariate associations with perceived oral healthCumulative

Predictor variable n odds ratio 95% CI

Income 282 1.47*‡ 1.27–1.71Age 429

18–39 140–53 0.85 0.55–1.3054π 0.58† 0.38–0.89

Gender 431Male 1Female 1.54 1.08–2.19

Ethnicity 431Chinese 1Indian 3.79 2.45–5.84Pakistani 7.46 4.35–12.80

Education 346Æ12 years 1.12 years 2.66 1.77–4.00

DMFT 4310–2 13–7 0.56 0.37–0.868π 0.43* 0.28–0.68

D/DMFT 3660% 1.0%–33% 0.86 0.52–1.44.33% 1.00 0.66–1.54

Missing teeth 4310 11 0.84 0.49–1.462π 0.45* 0.30–0.66

Number of years in US 4100–2 13–9 1.007 0.64–1.5810π 1.58 0.99–2.50

* P-value for trend ,0.001.† P-value for trend ,0.01.‡ OR per increase in income category.

also observed. The Chinese had a significantlyhigher DMFT score than the Pakistani. The Paki-stani had a significantly lower number of missingteeth than either the Chinese or Indian groups. Nodifferences in %D/DMFT were observed. The Chi-nese were more likely to report a worse perceptionof oral health than the other ethnic groups. Thisresult was also observed in the bivariate ordinallogistic regression analyses described below.

The bivariate associations between demographicand clinical variables with perception of oral healthfor the combined population are shown in Table 2.The following characteristics were predictive of abetter perception of oral health: higher income (P-value for trend ,0.001), younger age (P-value for

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trend ,0.01), female, non-Chinese, greater than 12years of education, lower DMFT score (P-value fortrend ,0.001), and a lower number of missing teeth(P-value for trend ,0.001). Actual or normativeneed of dental treatment, as defined by %D/DMFT,and number of years of residence in the US werenot significantly associated with perception of oralhealth. In the final multivariate model, only incomeand ethnicity were significant predictors of percep-tion of oral health after adjusting for DMFT (Table3). When separate analyses were performed foreach ethnic group (Table 4), the results were as fol-lows: among the Chinese there were no significantpredictors of perceived oral health in the bivariateanalyses; only income was strongly suggestivebased on the lower bounds of the confidence limitsfor the cumulative odds ratios which are close to1.00. In the final multivariate model (Table 5), in-come retained its marginal significance (P-value fortrendΩ0.06) after adjusting for DMFT. Among theIndian group, DMFT (P-value for trend ,0.01),number of missing teeth (P-value for trend ,0.001)and number of years in the USA were significantlyassociated with perception of oral health. In the fi-nal multivariate model, number of missing teethand number of years in US were independentlypredictive of perceived oral health. The magnitudeof the estimated cumulative odds ratios indicatesbetter oral health perception for subjects who havelived in the US for 3 or more years than for morerecent immigrants. Subjects with fewer missingteeth were also indicated to have better oral healthperception. For this analysis, number of missingteeth was analyzed as a continuous variable be-cause the stratum for exactly one missing tooth

Table 3. Final multivariate model of the combined group (nΩ282 subjects)

CumulativePredictor variable odds ratio 95% CI

Income 1.25*† 1.06–1.46

EthnicityChinese 1Indian 3.59 2.07–6.21Pakistani 4.66 2.28–9.54

DMFT0–2 13–7 0.59 0.35–1.008π 0.56 0.32–0.98

* P-value for trend ,0.01.† OR per increase in income category.‡ predictive ability of final model: cΩ0.71.

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Table 4. Bivariate associations with perceived oral health by ethnic group

Chinese Indian Pakistani

Cumulative Cumulative CumulativePredictor variable n odds ratio 95% CI n odds ratio 95% CI n odds ratio 95% CI

Income 134 1.33§ 0.98–1.81 97 1.19§ 0.95–1.48 51 1.24§ 0.90–1.73

Age 230 123 7618–39 1 1 140–53 0.54 0.29–0.99 1.47 0.65–3.34 1.41 0.53–3.7854π 0.86 0.49–1.53 0.64 0.26–1.54 0.45 0.11–1.82

Gender 231 124 76Male 1 1 1Female 1.53 0.94–2.48 1.34 0.69–2.60 1.23 0.50–2.98

DMFT 231 124 760–2 1 1 13–7 0.66 0.37–1.17 0.65 0.29–1.47 0.77 0.27–2.238π 0.58 0.31–1.07 0.49† 0.22–1.11 0.17‡ 0.048–0.57

DDMFT 203 104 590% 1 1 1.0%–33% 0.94 0.48–1.84 0.72 0.27–1.91 0.45 0.094–2.18.33% 0.90 0.50–1.59 0.80 0.35–1.84 0.65 0.022–1.94

Education 155 116 75Æ12 years 1 1 1.12 years 1.31 0.61–2.83 1.54 0.75–3.17 1.01 0.38–2.71

Missing teeth 231 124 760 1 1 11 0.59 0.28–1.25 2.27 0.82–6.27 0.52 0.12–2.312π 0.55 0.33–0.92 0.45* 0.22–0.93 0.58 0.16–2.01

Number of years in US 221 116 730–2 1 1 13–9 0.95 0.52–1.73 2.58 1.08–6.21 0.51 0.13–1.9710π 1.05 0.55–2.02 2.39 1.02–5.62 1.20 0.40–3.63

* P-value for trend ,0.001.† P-value for trend ,0.01.‡ P-value for trend ,0.05.§ OR per increase in income category.

was small for the Indian population (nΩ18) whichwould have yielded unstable estimates of cumula-tive odds ratios for that category. Among the Paki-stani group, DMFT was the only significant predic-tor in both the bivariate and multivariate analyses.

The c-statistics for all the final multivariate mod-els were quite high, indicating substantial correla-tion between observed responses and predictive re-sponses based on the models.

Discussion

Due to a paucity of research on the influence ofethnicity and culture in self-perception of oralhealth in the USA, little is known about whetherthe determinants associated with these self-percep-tions vary among ethnic subgroups.

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The results of this study suggest that there areethnic differences in the perception of oral healtheven after adjusting for clinical as well as demo-graphic variables in this group of Asian-Ameri-can residents of New York City. The predictorsassociated with the perception of oral health aredifferent for each of the subgroups studied,further suggesting differences in the conceptual-ization of oral health in each of these groups. Inthe combined multivariate analysis performed inthis study, the most important determinant ofself-perception of oral health was ethnicity (whencomparing the Indians and Pakistanis with theChinese). When the same analysis was performedwithin each of the subgroups, there was no com-mon significant predictor on multivariate anal-yses among them. Only DMFT was significant on

Self-perceived oral health among Asian-Americans

Table 5. Final multivariate models for the Chinese and Indiangroups

Chinese (NΩ134 subjects)

CumulativePredictor variable odds ratio 95% CI

Income 1.37* 0.99–1.89

DMFT0–2 13–7 0.49 0.23–1.038π 1.05 0.44–2.48

Indians (NΩ116 subjects)

CumulativePredictor variable odds ratio 95% CI

Missing teeth 0.84* 0.75–0.94

Number of years in US0–2 13–9 3.36 1.34–8.4310π 3.01 1.20–7.53

DMFT0–2 13–7 0.72 0.31–1.678π 0.77 0.25–2.40

* OR per increase in number of missing teeth and in incomecategory.

† predictive ability of final model: cΩ0.60; cΩ0.65 (respec-tively).

bivariate analysis for both the Indian and Paki-stani groups.

The clinical findings seemed to be more impor-tant for the self-perception of oral health of theIndians and Pakistanis than for the Chinese.Although the presence of actual or normativedisease (%D/DMFT) does not figure as a predictorof perception of oral health for these groups, hav-ing the ‘‘experience’’ of dental treatment, as il-lustrated by the number of missing teeth andDMFT, seemed to be a more important factor. Forthe Chinese group, only income was marginallysignificant on bivariate and multivariate analysis.However, this result needs to be interpreted cau-tiously because of the large number of missing dataon this variable. The reason for this was that theincome question was not included in some of thequestionnaires that were given to two of the Chi-nese organizations because their leaders regardedthat question to be potentially offensive to their cli-ents and objected to its inclusion in the survey.

To explore whether the Chinese subjects who an-swered the income question differed from thosewho did not, demographic and clinical characteris-

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tics were compared between the two groups. Theonly variable which was significantly different wasDMFT. Subjects who responded to the incomequestion tended to have a lower DMFT score (me-dianΩ4) than subjects with missing income infor-mation (medianΩ7; PΩ0.01). However, bivariateassociations of each of the predictor variables withperceived oral health did not differ in the twogroups, and the bivariate associations reported inTable 4 were not altered after excluding subjectswith missing income information (results notshown). Most importantly, the association of alower DMFT score with a better perception of oralhealth was consistent across income respondersand non-responders. In addition, since DMFT scorewas always adjusted for in the multivariate anal-yses, these results are not likely to be biased dueto the lower DMFT score observed among incomeresponders in the Chinese population.

As implied by this study, when analyzing datacombining several subgroups of larger racial/eth-nic groups, we run the risk of losing some of theinformation obtained if we do not take into consid-eration the ethnic or cultural variations betweenthe subgroups studied. When assessing the deter-minants of factors associated with the self-per-ceived oral health of diverse groups, we must lookbeyond the broad classifications of race and ethnic-ity commonly used in the USA and consider theinfluence that culture has in the individual sub-groups.

The results of this study appear to be similar toa recent study conducted in the USA where ethnici-ty was found to be one of the most significant pre-dictors of perceived oral health among a diversesample (23). Other studies comparing Asian-Americans and White Americans have also founddifferences in oral health beliefs and practices (28,29). Differences between White and Black individ-uals’ self-rated oral health have also been reported(15). Furthermore, ethnicity and maternal educa-tion has been found to be indicators of caries riskin the primary dentition (30). However, this prelim-inary study is the first comparing self-perceptionsof oral health among subgroups of a larger ethnicor racial classification.

There are several limitations to this study. Theassessment of self-perceptions of oral health utiliz-ing a single highly structured item carries with itrisks of structural bias. Furthermore, this studywas conducted on a convenience sample that maynot be representative of the larger population ofAsian-Americans in NYC. Although the results of

Cruz et al.

this preliminary study are not definitive, andshould be treated with caution, they suggest theneed for more studies on the perceptions of oralhealth among racial and ethnic subgroups.

In the USA, the ethnic and racial minorities andlow-income populations carry the heaviest burdenof oral health disease (10, 13, 31). In order to im-prove this situation, it is very important that weassess the determinants of this inequality and tailorour oral health promotion efforts according to theethnic and cultural characteristics of the particulargroups. Culture can influence interpretations ofdisease symptoms, its definitions and the care seek-ing behaviors of individuals (32). In a multiethnic,multiracial society, such as ours, several differentoral health promotion strategies must be devel-oped so they can reach all of those they are in-tended for.

Acknowledgements

This study was supported by grant no. P20 DE10593 (Re-search Center for Minority Oral Health, NYUCD/Forsyth)from the National Institute of Dental and Craniofacial Re-search, one of the institutes of the National Institutes ofHealth, Maryland, USA. We acknowledge the support of Dr.Donald Sadowsky during the initial evaluation of the resultsof this study.

We also would like to thank all of the examiners, recordersand interviewers who made this study possible.

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