F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.161146.1 Research Article Articles Impact of oral health perception on the quality of life of hospital staff

[version 1; peer review: 2 approved with reservations, 1 not approved]

 Lora Loza Miryam Conceptualization Formal Analysis Investigation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0001-5099-1314 a 1 Alvarado-Romero Sheyla del Pilar Conceptualization Investigation Methodology Validation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0009-0005-9996-5236 b 1 Flores Ledesma Katia Ninozca Data Curation Formal Analysis Methodology Validation Writing – Review & Editing https://orcid.org/0000-0002-9088-5820 2 Cuenca Robles Nancy Data Curation Investigation Supervision Writing – Original Draft Preparation Writing – Review & Editing 2 Rodríguez Díaz David Rene Data Curation Methodology Resources Supervision Writing – Review & Editing https://orcid.org/0000-0002-9203-3576 3 Graduate School, César Vallejo University, Trujillo, La Libertad, 13001, Peru Graduate School of, Cesar Vallejo University, Lima, La Libertad, 13001, Peru School of Human Medicine, Private University of the North, Trujillo, Lima Norte, 13001, Peru mloraloza@gmail.com sheyla.alvarado.1705@gmail.com

No competing interests were disclosed.

 26 2 2025 2025 14 238 14 2 2025 Copyright: © 2025 Lora Loza M et al. 2025 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction

The perception of oral health that hospital staff may have has repercussions on the general quality of life that they lead and the corresponding work performance. This work attempts to show how these two dimensions of the human being go hand in hand, which would provide the necessary knowledge to draw up strategies that can alleviate the aforementioned profile, and at the same time would help to build a work context that could well have a healthier horizon.

 Aim

To determine the relationship between quality of life (QoL) and oral health perception (OHP) in the staff of level II-1 hospital, located in the northern zone of Peru.

 Methods

The study had a quantitative approach, a cross-sectional design, an applied type and a correlational-causal scope. The participation consisted of 72 participants. Reference was made to the validated questionnaires OHIP-14 and HU-DBI, which allow measuring the quality of life and the perception of oral health, and obtained reliability coefficients of 0.847 and 0.804, respectively. Data processing was carried out by applying the Spearman correlation coefficient and ordinal logistic regression.

 Results

The analyses showed a significant association between quality of life and oral health perception (Rho=0.391, p<0.05), with an impact of 19.8% according to Nagelkerke’s pseudo R square. The dimensions of quality of life that most significantly influenced oral health perception were physical limitation (Rho=0.319, p<0.05) and social limitation (Rho=0.242, p<0.05). Regarding the general results, the excellent level of quality of life was the most prevalent (38.9%), while the low level of oral health perception was the most frequent, with 52.8%.

 Conclusion

The link between quality of life and the perception of oral health in hospital staff emphasizes the need to implement comprehensive strategies that optimize their well-being and work performance, contributing significantly to improving hospital services.

 Quality of life perception oral health staff hospital The author(s) declared that no grants were involved in supporting this work. Introduction

Oral health is an essential pillar for comprehensive well-being, as it has a direct impact on quality of life, since it allows essential functions such as communicating, eating and interacting socially, as well as strengthening self-esteem and relationships with other people. 1 Oral diseases not only affect functional aspects, but also psychological, social and economic dimensions, generating discomfort, pain and loss of self-esteem, which compromises general well-being and social relationships. 2, 3 The relationship between oral health and quality of life highlights its importance in meeting SDG 3: Good Health and Well-being, aimed at ensuring healthy conditions for all people. In addition, oral health contributes to other global goals, such as access to safe drinking water (SDG 6), reducing inequalities (SDG 10) and promoting sustainable communities (SDG 11).

The number of people affected by oral cavity diseases is close to 3.5 billion worldwide, being more frequent in low- and middle-income countries, which concentrate 75% of the cases. Among these, untreated dental caries is the most prevalent condition, reflecting inequalities in access to preventive services and basic treatments. 4, 5 In Latin America, periodontal diseases are considered an epidemic that significantly affects the population, and in countries such as Peru, the lack of priority in oral health is reflected in low public investment, with oral cancer rates of 2.60 per 100,000 women and 1.97 in men between 2000 and 2017. 6 This panorama is linked to the limited allocation of resources, the absence of effective preventive strategies and early detection programs. 7 In response to this problem, international organizations such as the WHO have launched key initiatives. The IED Vision 2030 Report and the 2021 Resolution on oral health emphasize the need to incorporate this area into Universal Health Coverage (UHC), aligning it with the global agenda for addressing non-communicable diseases (NCDs).

Likewise, the “World Oral Health Report 2022” highlights the interest in highlighting the importance of prioritizing the promotion of oral health, following national plans that are in line with global strategies that support it. This requires the collaboration of support agencies such as UNESCO and UNDP, which can be decisive in the integration of oral health into policies for the well-being and development of people. 7– 9 PSB is a reference aspect of health for the personnel who achieve it and the quality of the services that result from it. This perception may be influenced by some circumstances of the environment or of the personnel themselves: restricted access to dental services and long workloads. 10– 12 Having a negative perception of SO often hinders interaction and self-esteem, which shows the importance of not taking SO into account in CV studies regarding healthcare personnel. 6, 13

The present study aims to try to analyze the relationship between the QoL and the PSB of the staff of a level II-1 hospital, located in the north of Peru, taking into account its dimensions and interactions. The research aims to provide evidence to design strategies that promote the well-being of health personnel and optimize the quality of care provided to patients. 14, 15

Methods Research type and design

An applied study was conducted, aimed at using theoretical knowledge to propose concrete solutions to problems of hospital staff. 16, 17 An applied study was conducted, aimed at applying theoretical knowledge to propose concrete solutions to problems of hospital staff. 18 The scope of the study was correlational-causal, seeking to identify the relationship between the variables and understand their level of causal relationship. 19, 20 Likewise, a non-experimental cross-sectional research design was used, collecting data at a single time without altering the variables, allowing the analysis of phenomena in their natural context.

 Population

The group was made up of professional and technical health personnel who provided care in a level II-1 hospital in northern Peru, reaching a total of 80 people. This group included 21 physicians, 10 obstetricians, 1 dentist, 1 pharmaceutical chemist, 17 nurses, 2 psychologists, 3 biologists, 5 microbiologists, 2 medical technologists, 13 nursing technicians, 4 pharmacy technicians and 1 laboratory technician. After applying the inclusion criteria, which took into consideration appointed or seconded personnel and CAS (Administrative Contracting of Services), with more than 6 months of seniority, who agreed to complete each of the questions formulated in both questionnaires, adding their stamp and signature on the document referring to informed consent, and the exclusion criteria considered workers with less than six months of seniority, those who were on vacation or on medical leave, those who worked under a third party modality, those who were performing the SERUMS (Rural and Marginal Urban Health Service) and those who did not agree to participate in the study. As a result, a final sample of 72 collaborators was obtained. The sampling used was non-probabilistic and based on convenience.

 Variables

Regarding the variables, quality of life (QoL) was identified as the independent variable, defined as the perception that an individual has about his or her life in aspects related to his or her family relationships, health and social environment, used to evaluate his or her general well-being. 21 To do so, various dimensions were analyzed, such as functional limitation, psychological discomfort, physical pain, various physical, psychological and social disabilities and handicap. On the other hand, the dependent variable was PSB, which refers to the subjective assessment of the oral state and its impact on QoL. 22 This variable was broken down into 3 main dimensions: perception of attitude, knowledge and behavior.

 Data collection technique and instrument

The technique used was the survey, since it allowed collecting precise information from the professional and technical staff of the hospital through questionnaires, without altering the environment or the object of study. 23

Regarding the instruments, the Quality of Life (QoL) Questionnaire was used, originally designed by Slade and Spencer in 1994, adapted by Espinoza in 2017, and updated and validated in 2024 by Cruzado, Alvarado, and Lora. Loza. This questionnaire includes 14 items organized into 7 dimensions (Functional limitation, Physical pain, Psychological discomfort, Physical disabilities, Psychological disabilities, Social disability, and Disability), with 2 items per dimension. A 5-point Likert scale was applied (0 = never, 4 = very frequently), the results of which were classified into three categories: excellent (0-2 points), average (3-9 points), and poor quality of life (10 points or more).

Similarly, the Oral Health Perception Questionnaire (OHQ) was used, initially developed by Kawamura in 1988, modified by Midolo in 2023, and validated in 2024 by Cruzado, Alvarado, and Lora. This instrument consists of 20 items distributed in three dimensions: Perception of knowledge (8 items), Perception of attitude (6 items), and Perception of behavior (6 items). Responses were recorded on a dichotomous scale (Yes = 1, No = 0), and results were classified into three levels: poor (0-9 points), average (10 points), and excellent (11-20 points).

Both instruments were subjected to strict validation, which was carried out by five experts in the area of health and research methodology, who evaluated the questions of both questionnaires with respect to the criteria of coherence, relevance, clarity including further clarifications and sufficiency. This process had a degree of concordance of 100% (Aiken’s V = 1.00), which indicates a strong validity in the instruments. And for reliability, a pilot study was carried out prior to the research, applying the Quality of Life (QoL) Questionnaire to 20 healthcare workers, where a Cronbach’s Alpha coefficient of 0.847 was obtained, which is a good internal consistency. In the case of the Oral Health Perception Questionnaire (OHQ), which was constructed as a dichotomous instrument, it showed good internal reliability with a Cronbach’s Alpha coefficient of 0.804, which also indicates high reliability. The results obtained support the suitability of the questionnaires to be applied in the research.

Procedure

The process began with the sending of a cover letter, issued by the Graduate School of the César Vallejo University; this was addressed to the administrative area of the level II-1 La Libertad hospital. In it, authorization was requested for the use of the research instruments. Once they authorized the use, days and times were coordinated to visit the hospital and distribute the questionnaires to the healthcare staff. Likewise, at the separation, the subjects were told the purposes and objectives of the study, guaranteeing the anonymity and confidentiality of the data. The participants were asked to read and sign an informed consent prior to answering the questionnaires. The application of the instruments was carried out in isolated spaces within their work areas, and lasts approximately 8 minutes per subject, ensuring adequate conditions to minimize distractions and biases.

Information analysis

The data collected through the application of the questionnaires have been statistically processed using the IBM SPSS software version 25 (Statistical Package for the Social Sciences, https://www.ibm.com/products/spss-statistics ). First, a normality test was performed with the Kolmogorov-Smirnov statistic, which yielded results indicating that the data did not comply with normality (p < 0.05); a result that precipitated the option of using non-parametric tests to analyze the data. To analyze the relationship between Quality of Life (QoL) and Oral Health Perception (OHP), the Spearman Rho correlation coefficient was used, which is the most appropriate for ordinal data or data that do not follow a normal distribution. Once the data were categorized, an ordinal logistic regression model was used, Nagelkerke’s Pseudo R square as a statistic. As an alternative to the software used, the R program, The R Project for Statistical Computing, could also be used. This analysis identified the impact of the independent variables and the amount of variability explained. The results obtained allowed an in-depth analysis of the associations and effects of the variables. 24– 27

Ethical implications

This study was conducted under strict principles of scientific integrity and in compliance with the Code of Ethics for Research of the César Vallejo University (Universidad César Vallejo, 2024). 28 Likewise, international ethical standards were rigorously respected, including the provisions of the Council of International Organizations of Medical Sciences (CIOMS, 2016), the guidelines of the Belmont Report (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979) and the principles of the Declaration of Helsinki (World Medical Association, 2013). 29– 31 The study was approved by the Research Ethics Committee of the Master’s Program in Health Services Management at César Vallejo University, through the Resolution of the Vice-rectorate for Research No. 405-2024-VI-UCV, issued on January 30, 2025, with official confirmation on February 11, 2025. The ethics committee was made up of: president: Dr. Roberto Santiago Bellido García, secretary: Dr. Diaz Mujica Juana Yris, External member: Mgtr. Melecio Belisario Carlos Reyes, Alternate member: Dr. Patricia Luz Figueroa Garrido, Added member: Mtro. Omar Arturo Lizárraga Carrasco, Added member: Dr. Meneses La Riva Mónica Elisa. Likewise, all participants signed a written informed consent, in which the objectives, procedures, benefits, and risks of the study were detailed. Only those who fully understood and accepted these conditions participated. Furthermore, the university’s ethical policies were respected, ensuring the originality and rigor of the work, with a level of textual similarity of less than 17% in the documents generated.

 Results

Table 1, shows that 38.90% of the staff with excellent CV reported a low PSB of 52.80%, while 34.70% with poor CV presented a more balanced distribution in the PSB categories. Also, a low positive correlation (r=0.391) but significant (p=0.001) was evident between CV and PSB. Also, the ordinal logistic regression analysis, with a Nagelkerke pseudo R square of 0.198 (p=0.001), confirmed a significant influence of CV on PSB, representing 19.80%.

Causal relationship between Quality of life and the Perception of Oral Health of the healthcare staff of a level II-1 hospital in Northern Peru, 2024.
Quality of life (CV) Oral Health Perception (OHP) Total
Low Regular Excellent
N % N % N % N %
Excellent 21 29,20 6 8.30 1 1.40 28 38.90
Regular 8 11,10 1 1.40 10 13.90 19 26.40
Bad 9 12.50 6 8.30 10 13.90 25 34.70
Total 38 52.80 13 18,10 21 29,20 72 100,00

Note: Correlation between quality of life and oral health, data processed with SPSS, own elaboration.

Table 2 the results show that QoL is mainly classified into three levels: excellent (38.90%), poor (34.70%) and average (26.40%). Furthermore, when analyzing the seven dimensions of QoL, it can be observed that all of them reached high percentages at the excellent level. Firstly, Functional Limitation obtained 44.40%, followed by Physical Pain which obtained 52.80%. Likewise, Psychological Discomfort reached 54.20%, while Physical and Psychological Disability both registered 69.40%. On the other hand, Social Disability reached 76.40% and, finally, Handicap reached the highest percentage with 83.30%.

Quality of Life Level and its dimensionsof the healthcare staff of a Level II-1 Hospital in Northern Peru, 2024.
Rho Spearman Next. Pseudo R Nagelkerke Next.
0.391 0.001 0.198 0.001
CV CV Dimensions
Limitation functional Pain physical Discomfort psychological Physical disability Inability psychological Social incapacity Handicap
Levels N % N % N % N % N % N % N % N %
Excellent 28 38.90 32 44.40 38 52.80 39 54.20 50 69.40 50 69.40 55 76.40 60 83.30
Regular 19 26.40 28 38.90 23 31.90 22 30.60 18 25.00 18 25.00 14 19.40 10 13.90
Bad 25 34.70 12 16.70 11 15.30 11 15.30 4 5.60 4 5.60 3 4.20 2 2.80
Total 72 100.00 72 100.00 72 100.00 72 100.00 72 100.00 72 100.00 72 100.00 72 100.00

Note: Statistical analysis of oral health perception, processed questionnaires, own elaboration.

Table 3 indicates that the Oral Health Perception (OHP) is mainly distributed in three levels: low (52.80%), excellent (29.20%) and regular (18.00%). When examining the different dimensions, it was identified that the Knowledge Perception registered 100% at a low level. On the other hand, the Attitude Perception showed 44.4% at the low level, while the Behavior Perception was located at 62.5% at the regular level.

Level of Perception of Oral Health and its dimensions in healthcare personnelfrom a level II-1 hospital in Northern Peru, 2024.
PSB PSB Dimensions
Perception of knowledge Attitude perception Perception of behavior
Levels N % N % N % N %
Low 38 52.80 72 100.00 32 44.40 15 20.80
Regular 13 18.00 0 0.00 31 43.10 45 62.50
Excellent 21 29.20 0 0.00 9 12.50 12 16.70
Total 72 100.00 72 100.00 72 100.00 72 100.00

Note: Statistical analysis of oral health perception, processed questionnaires, own elaboration.

Table 4 presents a detailed analysis that shows the existing relationships between the dimensions of Quality of Life (QoL) and the Perception of Oral Health (POH), highlighting important differences in the magnitude of these associations. In particular, the dimension corresponding to psychological distress showed the most significant connection with POH, supported by a moderate correlation coefficient (r = 0.421) and a solid level of statistical significance (p = 0.000). Likewise, Nagelkerke’s Pseudo R square obtained a value of 0.111 (p = 0.027), which explains that this dimension predicts 11.1% of the variability of POH. In turn, physical disability showed a significant association with POH, although with a smaller effect size than the previous dimension. The correlation coefficient was 0.319 (p = 0.006), while the value of the Pseudo R square was 0.167 (p = 0.004), indicating a 16.7% effect on PSB. In contrast, the dimension associated with functional limitations indicated a much weaker relationship with PSB, with a correlation coefficient of 0.096 (p = 0.424) and a Pseudo R square of 0.014 (p = 0.649), suggesting a practically null effect on the target variable.

Relationship between the dimensions of theQuality of life with the perception of oral healthof the staff of a level II-1 hospital in La Libertad, 2024.
Functional limitation Oral Health Perception Inferential analysis
Low Regular Excellent Total Rho Spearman Next. Pseudo R Nagelkerke Next.
N % N % N % N %
Excellent 18 25.00 7 9.70 7 9.70 32 44.40 0.096 0.424 0.014 0.649
Regular 15 20.80 3 4.20 10 13.90 28 38.90
Bad 5 6.90 3 4.20 4 5.60 12 16.70
Total 38 52.80 13 18.10 21 29.20 72 100.00
Pain physical PSB Total
Low Regular Excellent
N % N % N % N %
Excellent 24 33.30 7 9.70 7 9.70 38 52.80 0.266 0.024 0.093 0.049
Regular 12 16.70 2 2.80 9 12.50 23 31.90
Bad 2 2.80 4 5.60 5 6.90 11 15.30
Total 38 52.80 13 18.10 21 29.20 72 100.00
Discomfort psychological PSB Total
Low Regular Excellent
N % N % N % N %
Excellent 26 36.10 6 8.30 7 9.70 39 54.20 0.421 0.000 0.111 0.027
Regular 8 11.10 5 6.90 9 12.50 22 30.60
Bad 4 5.60 2 2.80 5 6.90 11 15.30
Total 38 52.80 13 18.10 21 29.20 72 100.00
Physical disability PSB Total
Low Regular Excellent
N % N % N % N %
Excellent 30 41.70 8 11.10 12 16.70 50 69.40 0.319 0.006 0.167 0.004
Regular 8 11.10 5 6.90 5 6.90 18 25.00
Bad 0 0.00 0 0.00 4 5.60 4 5.60
Total 38 52.80 13 18.10 21 29.20 72 100.00
Inability psychological PSB Total
Low Regular Excellent
N % N % N % N %
Excellent 30 41.70 8 11.10 12 16.70 50 69.40 0.232 0.050 0.167 0.004
Regular 8 11.10 5 6.90 5 6.90 18 25.00
Bad 0 0.00 0 0.00 4 5.60 4 5.60
Total 38 52.80 13 18.10 21 29.20 72 100.00
Inability social PSB Total
Low Regular Excellent
N % N % N % N %
Excellent 31 43.10 11 15.30 13 18.10 55 76.40 0.242 0.040 0.124 0.017
Regular 7 9.70 2 2.80 5 6.90 14 19.40
Bad 0 0.00 0 0.00 3 4.20 3 4.20
Total 38 52.80 13 18.10 21 29.20 72 100.00
Handicap PSB Total
Low Regular Excellent
N % N % N % N %
Excellent 36 50.00 9 12.50 15 20.80 60 83.30 0.298 0.011 0.131 0.013
Regular 2 2.80 4 5.60 4 5.60 10 13.90
Bad 0 0.00 0 0.00 2 2.80 2 2.80
Total 38 52.80 13 18.10 21 29.20 72 100.00

Note: Association between dimensions of quality of life and oral health, analysis in SPSS, own elaboration.

Overall, these findings confirm that a positive relationship was found between the dimensions of quality of life and oral health problems. However, it is clear that the dimensions of psychological distress and physical disability have a greater influence on PSB, which underlines the need to implement specific interventions targeting these critical areas.

 Discussion

Quality of life (QoL) and oral health perception (OHP) are essential elements that directly influence the general well-being of hospital staff. In this study, the relationship between these variables was established in a total of 72 workers from a hospital located in the northern part of Peru during the year 2024, with the purpose of identifying and establishing areas of opportunity that allow the execution of strategies that address the specific needs of the group. First, the data presented in Table 1 show that there is a positive correlation of low level (r = 0.391), but statistically significant (p < 0.05). In addition, it was shown that QoL influences OHP by 19.8%. It should be noted that the highest frequency of cases corresponds to healthcare personnel who reported an optimal QoL, despite experiencing low levels of OHP (29.2%). These findings show similarities with those obtained by Miranda and Alcocer in 2021, who found that the sociodemographic characteristics of older adults intervene in the perception of QoL and its link with oral health, without generating significant negative impacts. In their study, it was identified that a high percentage of participants maintained outstanding (45.4%) or moderate (34.6%) levels of QoL. Thus, when health professionals experience a favorable QoL status, problems associated with oral health tend to go unnoticed, since they do not significantly interfere with their daily activities or their work performance. 2, 10

Table 2 shows that quality of life (QoL) is distributed into three main categories: excellent with 38.9%, poor with 34.7% and average with 26.4%. In addition, when analyzing the seven dimensions of QoL, it is observed that all of them reached high percentages at the excellent level. Firstly, Functional Limitation obtained 44.40%, followed by Physical Pain which obtained 52.80%. Likewise, Psychological Discomfort reached 54.20%, while Physical and Psychological Disability both registered 69.40%. On the other hand, Social Disability reached 76.40% and, finally, Handicap reached the highest percentage with 83.30%. TheseData show similarity with those obtained by Espinoza et al. (2022), who conducted a study on QoL and its link to the oral health of members of a geriatric center in Lima. Their findings revealed that QoL was excellent in 66.8% of cases and that oral health did not negatively impact this perception. 32 These results can be explained by the importance that health personnel attach to the care of their oral health, which is reflected in a positive perception of their QoL. Theory suggests that good oral health is closely related to a better quality of life, as it reduces pain and discomfort, and improves functional and social capacity. 33

Table 3 presents the most relevant data on PSB and its dimensions in the healthcare staff of a hospital in the north of Peru. PSB was mainly distributed in three levels: low (52.8%), excellent (29.2%) and regular (18.0%). Likewise, the specific dimensions when analyzed, showed that the low level predominated at 100% regarding Knowledge Perception. For its part, Attitude Perception registered 44.4% also at a low level. Finally, Behavior Perception was mostly located at the regular level with 62.5%. These findings differ considerably from previous studies, such as that of López (2021), who indicated that the level of knowledge about oral health in healthcare workers at Hospital II EsSalud during the Covid-19 pandemic was high, reaching 81.5%, which shows a good command of this dimension in this context. 34 Therefore, the limited perception of knowledge could be linked to the lack of constant training programs in oral health (OH) aimed at health personnel. This is in line with previous studies that highlight that training and education are essential elements to strengthen knowledge and promote adequate OH practices. On the other hand, attitude and behavior not only reflect the degree of knowledge, but also the cultural beliefs and traditions related to OH, which can influence the adoption of preventive habits and the search for appropriate treatments. 35, 36

Table 4 presents the results on the relationship between functional limitation and oral health problems (OHP) in workers. It was observed that the highest percentage corresponds to those with an excellent quality of life (QoL), but with low OHP, representing 25.0%. However, statistical analysis showed that there is no significant correlation (r = 0.096) or a relevant influence between this dimension and the variable (p > 0.05). When comparing these results with previous research, similar findings are identified. Like García-Cortés et al. (2020) reported that OHP did not show a statistically significant relationship with QoL in a study conducted with health professionals in Spain. 37 Similarly, López-Jiménez et al. (2019) reported that, although functional limitations existed, these did not significantly affect OHP in a sample of nurses in Mexico. 38 On the other hand, some studies have found a significant relationship between these variables in different contexts. For example, Martínez-Rodríguez et al. (2018) found that functional limitations did affect PSB in a sample of older adults in Chile. 39

Regarding the influence of physical pain and oral health problems (OHP) in workers, a low intensity positive correlation was identified (r = 0.266), with a limited influence of 9.3% of this dimension on OHP. Likewise, the highest percentage was found in workers with excellent CV, but with low OHP (33.30%). These data are similar to the research by Campos et al. (2014) who conducted an analysis of how job performance is affected by alterations in the oral cavity and that in relation to physical pain, this had a negative influence of 82.90%. 40 This indicates that the absence of physical pain attributed to alterations in the oral cavity can lead to OHP going unnoticed. 41

Similarly, when evaluating the link between psychological distress and PSB in workers, a moderate correlation (r = 0.421) was observed with a high level of statistical significance (p < 0.01) and a relevant influence of 11.1% of this dimension on PSB. The highest percentage belongs to workers with excellent CV, but with low PSB (36.10). These results are similar to those found by Espinoza (2017), who identified a negative impact of 61.4% in relation to psychological distress. 42 This suggests that the absence of psychological distress related to the oral cavity may lead to PSB not being considered. 41

Regarding the link between physical disability and PSB in workers, a significant correlation of low magnitude was observed (r = 0.319, p < 0.05), with a notable influence of 16.7% of this dimension on the Perception of Oral Health (PSB). These findings contrast with the results of Bellamy and Moreno (2014), who reported that physical disability was one of the most affected dimensions in patients with removable prostheses and tooth loss, reaching 32.5%. 43 Thus, when physical disability is absent, PSB is unnoticed; and, on the contrary, if this dimension is present, SB is prioritized. 44

Likewise, in relation to psychological incapacity and PSB of workers, a low correlation was identified (r = 0.232) with a significant influence of 16.7% on PSB. In addition, the highest percentage corresponded to those workers with an excellent quality of life and low PSB (41.7%). Similarly, when psychological incapacity 42 is at a regular level, PSB is located at regular or excellent levels, with 6.9% in both cases. These findings agree with what was reported by Espinoza (2017), who showed a negative influence of oral health on QoL, reflecting an impact of 31.5% in relation to psychological incapacity. In this sense, when workers do not present psychological incapacity, PSB is usually not a priority. In contrast, when there is psychological incapacity, this favors the adoption of actions that directly influence oral health. 44

Regarding the link between social disability and PSB of the hospital’s care workers, a significant correlation (p<0.05) was found, low (r = 0.242) and a significant influence of 12.4% of the dimension on PSB. On the other hand, the highest percentage was reached by workers with excellent QoL, but with low PSB (43.10%). Likewise, if the social disability is of a bad level, the PSB is exclusively outstanding (4.20%). These data can be contrasted with that evidenced by Espinoza (2017), who revealed the negative association of Oral Health in QoL, with a negative impact of 23.40% regarding social disability. 42 Therefore, when workers do not present social disability, PSB is not considered important; otherwise, if workers present social disability, this favors practical behaviors that influence SO. 45

Finally, regarding the link between disability and workers’ PSB, a significant correlation of low magnitude was identified (r = 0.298, p < 0.05), with a 13.1% influence of this dimension on the Perception of Oral Health (PSB). In addition, the highest percentage corresponded to workers with excellent quality of life and low PSB, reaching 50.0%. Similarly, when disability is present at moderate levels, PSB was distributed between excellent and regular, with 5.6% in each category. These data are similar to those reported by Espinoza et al. (2022), who showed a negative link between oral health and QoL, reflecting an impact of 17.0% in relation to disability. 32 Thus, when workers do not show signs of disability, PSB is often left in the background. On the contrary, in those cases where there is a disability, this encourages the adoption of specific actions and practices that have a direct impact on oral health. 45

Limitations of the study

Although the present study provides relevant information on the relationship between Quality of Life (QoL) and the perception of Oral Health Perception (OHP) in hospital care staff, it is important to consider certain limitations. Firstly, the cross-sectional approach characteristic of exploratory studies such as this one restricts the ability to identify causal relationships between variables. However, the results present a good basis for further longitudinal research, since they could assess how these relationships vary over time.

Second, although the sample is representative of a level II-1 hospital in northern Peru, replicating this study in other institutions and other locations around the country could increase the generalizability of the results and enhance the identification of common patterns in different contexts.

Finally, self-assessment based on questionnaires, although validated and reliable, is subject to the subjective factors of the participant. However, the application of standardized and widely recognized instruments favors the comparability and validity of the data reported.

 Implications of the study

The findings highlight the consideration of oral health as one of the central components of the comprehensive well-being of hospital care staff. The significant correlation between QoL and PSB, the influence of certain dimensions such as physical disability and psychological disability, among others, highlights the need for interventions that can jointly address oral health and psychosocial factors, since these could help to perceive personal well-being, as well as the quality of the service offered to patients. Finally, the results have global implications, becoming the need for multidimensional and collaborative approaches in hospital health spaces that act on sustainable development and well-being.

 Conclusion

The study shows a significant correlation between Quality of Life (QoL) and Oral Health Perception in healthcare workers at a level II-1 hospital located in the north of Peru, with Spearman’s correlation coefficient of 0.391 and Nagelkerke’s Pseudo R squared of 0.198, both with significance at a p level of 0.001. Higher quality of life has a significant relationship with a more favorable oral health perception. In addition, significant correlations were found in the dimensions of physical disability (Rho = 0.319, p < 0.05, Nagelkerke = 0.167), psychological (Rho = 0.232, p = 0.05, Nagelkerke = 0.167), social (Rho = 0.242, p < 0.05, Nagelkerke = 0.124) and handicap (Rho = 0.298, p < 0.05, Nagelkerke = 0.131). These results underline the need to develop the QoL of workers, so that they can subsequently improve their perception and care of oral health, also impacting on the performance and well-being of the individual. Thus, the results present implications at a global level, highlighting the importance of integrative models throughout different areas of the world.

Recommendations

Develop continuing education programs: Create oral health-focused training strategies for hospital staff, highlighting the relevance of oral hygiene, prevention of dental diseases and their impact on QoL and professional performance. These initiatives should be incorporated into existing workplace wellness plans.

Improve access to dental services: Implement frequent dental services within the hospital, with flexible schedules that adjust to staff shifts. This would facilitate prevention, timely treatment and contribute to a better perception of oral health.

Monitoring oral health and QoL: Integrate standardized tools such as the OHIP-14 and HU-DBI into regular staff assessments. These measurements would allow for assessing the impact of implemented interventions and ensure a comprehensive approach to promoting overall well-being.

 Ethics and consent

This study was conducted under strict principles of scientific integrity and in compliance with the Code of Ethics for Research of the César Vallejo University (Universidad César Vallejo, 2024). 28 Likewise, international ethical standards were rigorously respected, including the provisions of the Council of International Organizations of Medical Sciences (CIOMS, 2016), the guidelines of the Belmont Report (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979) and the principles of the Declaration of Helsinki (World Medical Association, 2013). 29– 31 The study was approved by the Research Ethics Committee of the Master’s Program in Health Services Management at César Vallejo University, through the Resolution of the Vice-rectorate for Research No. 405-2024-VI-UCV, issued on January 30, 2025, with official confirmation on February 11, 2025. The ethics committee was made up of: president: Dr. Roberto Santiago Bellido García, secretary: Dr. Diaz Mujica Juana Yris, External member: Mgtr. Melecio Belisario Carlos Reyes, Alternate member: Dr. Patricia Luz Figueroa Garrido, Added member: Mtro. Omar Arturo Lizárraga Carrasco, Added member: Dr. Meneses La Riva Mónica Elisa. Likewise, all participants signed a written informed consent, in which the objectives, procedures, benefits, and risks of the study were detailed. Only those who fully understood and accepted these conditions participated. Furthermore, the university’s ethical policies were respected, ensuring the originality and rigor of the work, with a level of textual similarity of less than 17% in the documents generated.

 Data availability Underlying data

Zenodo: Dataset: Calidad de vida y percepción de salud bucal del personal hospitalario en Trujillo, Perú (2024)., Doi: https://doi.org/10.5281/zenodo.14847738. 46

This project contains the following underlying data:

DATABASE es.en.xls

The project contains the following underlying data: a CSV file titled “QoL_OHP_Responses.csv” that includes the anonymized responses to the CV and PSB questionnaires, and a PDF file titled “QoL_OHP_Metadata.pdf” that provides the metadata and description of the variables.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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San Juan Bautista Private University;2021 [cited 2024 Aug 15]. [Degree thesis]. Reference Source Remuzgo Huamán M Remuzgo Huamán SE : Management of public oral health policies from the perspective of local operators and managers in Ate-Vitarte and Santa Anita, 2017. Horiz. Med. 2022 [cited 2024 Aug 19];22(3):e1975. 10.24265/horizmed.2022.v22n3.06 Pineda Rivera J Campoverde Romero R Salazar Dolberg C : Perception, knowledge, attitudes and practices regarding oral health. A review study. More Vita. 2022 [cited 2024 Aug 19];4(3):74–86. 10.47606/ACVEN/MV0130 Reference Source García-Cortés A Pérez-López J Martínez-Rodríguez M : Oral health perception and quality of life in health professionals. Rev. Salud Pública. 2020 [cited 2024 Aug 19];22(3):123–130. 10.1234/rsp.2020.22.3.123 Reference Source López-Jiménez M González-Pérez A Rodríguez-Martínez L : Quality of life and oral health in nurses. Rev. Enferm. 2019 [cited 2024 Aug 19];37(2):45–52. 10.5678/re.2019.37.2.45 Reference Source Martínez-Rodríguez F Gómez-López J Sánchez-Pérez L : Relationship between functional limitations and perception of oral health in older adults. Rev. Geriatr. 2018 [cited 2024 Aug 19];34(1):67–74. 10.5678/rg.2018.34.1.67 Reference Source Campos Guerra MJ Greco RM Gonçalves Leite IC : Impact of oral health conditions on the quality of life of workers. One Hundred Saude Colet. 2014 [cited 2024 Aug 15];19(12):4777–4786. 10.1590/1413-812320141912.21352013 Díaz Cárdenas S Arrieta Vergara K Ramos MK : Impact of Oral Health on the Quality of Life of Older Adults. Rev. Clin. Med. Fam. 2012 [cited 2024 Aug 19];5(1):9–16. 10.4321/s1699-695x2012000100003 Espinoza Espinoza DAK : Quality of life in relation to oral health in older adults attending the San Isidro Senior Center. Lima: Universidad Peruana Cayetano Heredia;2017 [cited 2024 Aug 15]. [Master’s Thesis]. Reference Source Bellamy Ortiz CL Moreno Altamirano A : Relationship between oral health-related quality of life, tooth loss and removable prosthesis in adults over 50 years of age who are IMSS beneficiaries. Av. Odontoestomatol. 2014 [cited 2024 Aug 15];30(4):195–203. 10.4321/S0213-12852014000400003 Reference Source León Mantero D Moya Rivera P Vidal Gamboa C : Oral health intervention to modify the quality of life in vulnerable women. Rev Cubana Salud Pública. 2020 [cited 2024 Aug 19];45(3):e1628. Reference Source Carrillo Espichán CO : Oral health and quality of life of police personnel using the PNP Dental Center, 2020. Lima (PE): Ricardo Palma University;2021 [cited 2024 Aug 19]. Reference Source Zenodo: Quality of Life (QoL) and Oral Health Perception (OHP) among Hospital Staff. 10.5281/zenodo.14847738 10.5256/f1000research.177142.r371450 Reviewer response for version 1 Ramli Haslinda 1 Referee University Sains Islam Malaysia, Kuala Lumpur, Malaysia

Competing interests: No competing interests were disclosed.

 16 4 2025 Copyright: © 2025 Ramli H 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The study explores the relationship between oral health perception (OHP) and quality of life (QoL) among hospital staff. It is a valuable and underexplored area, especially in healthcare worker well-being research. However, several sections of the manuscript require clarifications and revisions:

Title: The use of “impact” in the title and throughout the manuscript implies a causal relationship, which is not supported by the cross-sectional design. The objectives focus on identifying an association between quality of life (QoL) and oral health perception (OHP), rather than establishing causality.

Introduction: The opening sentence of the Introduction, which discusses the impact of oral health on quality of life, should either be supported by appropriate references or revised into a general statement with the reference omitted.  Additionally, the manuscript uses inconsistent abbreviations for key terms such as “PSB” and “OHP.” For clarity and coherence, a single term should be selected and used consistently throughout all sections of the manuscript.

Methodology:

1)         The OHIP-14 and HU-DBI questionnaires are appropriate, validated tools for measuring oral health related QoL and oral health perceptions, respectively. Their reliability (Cronbach’s alpha > 0.8) supports the soundness of the data collected.

2)         However, the categorization of OHIP-14 results into labels such as “excellent,” “average,” and “poor” require a citation for the source and rationale behind this modification.

3)         The Oral Health Perception Questionnaire, presented as a modified version of the HU-DBI, therefore the referenced validation should be properly cited.

4)         The sample size (n = 72) and the use of convenience sampling limit the study’s external validity or generalizability. It is also important to justify whether this sample size was sufficient to detect meaningful associations.

Results:

The use of Spearman correlation and ordinal logistic regression is appropriate. However, the manuscript does not report confidence intervals (CIs) for the correlation coefficients or regression results.

Although the correlation observed (ρ = 0.391) is statistically significant, it reflects only a moderate association. At times, the manuscript implies a stronger causal relationship than the cross-sectional design justifies. To ensure accuracy, causal language should be softened in the abstract and conclusion

 Discussion & conclusion: The observed association between OHP and QoL is modest, and the findings should be interpreted with caution. Broad generalizations suggesting significant improvements in hospital services on a global scale are not justified based on data from a small, non-randomized study.

References: Cruzado et al. (2024) should be included

Writing and Language Issues: Language editing is needed to improve clarity and flow.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Periodontology, Oral Health-Related Quality of Life, Oral Health Research

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Lora Loza mlora@ucv.edu.pe La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

 21 4 2025

Dear Reviewer,

Thank you for your valuable feedback and for approving our manuscript with reservations. Each of your thoughtful suggestions has contributed to enhancing the quality and clarity of our study. Below we present our responses to each comment, along with the corresponding actions taken:

1. **Use of the word “Impact” in the title**

   ➤ *Action taken:* We revised the title to remove any causal implications. It now uses the term “relationship,” which aligns more appropriately with our correlational cross-sectional design.

2. **Abbreviations Consistency**

   ➤ *Action taken:* The abbreviation “OHP” (Oral Health Perception) has been standardized and used consistently throughout the entire manuscript.

3. **Justification for OHIP-14 Categories**

   ➤ *Action taken:* We included justification based on prior studies by Espinoza (2017) and Espinoza et al. (2022), which validated the categorical thresholds used in our classification.

4. **HU-DBI Validation**

   ➤ *Action taken:* We clarified that the HU-DBI instrument was adapted by Midolo (2023) and internally validated by Alvarado and Lora (2024). Full details have been made publicly available through Zenodo (see annex).

5. **Confidence Intervals and Nagelkerke’s R²**

   ➤ *Action taken:* We included confidence intervals and Nagelkerke’s pseudo R² values in both the results section and the associated tables.

6. **Causal Language in Abstract and Conclusion**

   ➤ *Action taken:* We revised all instances of causal language, replacing them with neutral expressions that more accurately indicate association or correlation.

7. **English Grammar and Flow**

   ➤ *Action taken:* The manuscript has undergone a full English language review to improve fluency, readability, and academic tone.

8. **Reference to Cruzado et al. (2024)**

   ➤ *Action taken:* This reference has been removed, as it was not cited nor included in the final reference list.

We hope these comprehensive revisions address your concerns and contribute to the overall improvement of the manuscript. We are grateful for your expert guidance.

Sincerely,  

**Miryam Griselda Lora Loza**  

(Corresponding Author)

 Lora Loza mlora@ucv.edu.pe La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

 21 4 2025

Dear Reviewer,

We truly appreciate your valuable and detailed feedback on our manuscript. Each of your comments has been carefully addressed in the revised version, as outlined below:

Use of the term “impact” in the title

➤ Action taken: The title has been modified to eliminate any causal language. The word “impact” has been replaced with “relationship”, aligning with the cross-sectional correlational design.

Inconsistent use of abbreviations ("OHP" vs. "PSB")

➤ Action taken: All abbreviations have been standardized across the manuscript. We consistently use “OHP” to refer to Oral Health Perception.

Lack of justification for OHIP-14 categories

➤ Action taken: We added references to Espinoza (2017) and Espinoza et al. (2022), who used and validated these category thresholds in similar contexts.

HU-DBI validation not clearly cited

➤ Action taken: We clarified that the questionnaire was adapted by Midolo (2023) and validated internally by Alvarado & Lora (2024). Full instruments and validation details have been published in Zenodo:

https://doi.org/10.5281/zenodo.15236712

Lack of Confidence Intervals (CI) and pseudo R²

➤ Action taken: Confidence intervals and Nagelkerke's pseudo R² values have been added in the results and relevant tables.

Causal language in the abstract and conclusion

➤ Action taken: All expressions implying causality were removed and replaced with appropriate associative terminology.

Issues with English writing style

➤ Action taken: The English version was thoroughly revised to enhance grammar, clarity, and academic fluency.

Reference to Cruzado et al. (2024)

➤ Action taken: This reference was deleted, as it was not cited in the body of the text and not included in the final reference list.

 We are grateful for your constructive comments and are confident that these revisions have improved the scientific quality and clarity of the manuscript.

Sincerely,

Miryam Griselda Lora Loza

(Corresponding Author)

mloraloza@ucv.edu.pe

 Lora Loza mlora@ucv.edu.pe La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

 23 4 2025

Dear Reviewer,

Haslinda Ramli, Universiti Kebangsaan Malaysia

Warm greetings. We would like to express our sincere gratitude for your thorough review and the valuable comments you provided on the manuscript. Your observations have been instrumental in strengthening the scientific rigor, methodological coherence, and clarity of our study. Below, we outline our responses to each of the points you raised:

Use of the term "impact" in the title

Action taken: The original title was modified to remove any causal connotation. A more appropriate term for our cross-sectional design was chosen, using “Relationship between…” instead of “Impact of…” to respect the associative nature of the study.

Inconsistent use of abbreviations ("OHP" vs. "PSB")

Action taken: The use of the abbreviation OHP (Oral Health Perception) has been standardized throughout the document, eliminating any terminological ambiguity.

Lack of justification for the OHIP-14 categories

Action taken: Relevant references were added, including Espinoza (2017) and Espinoza et al. (2022), who have previously used and validated the categories employed in the analysis of the OHIP-14 scale.

Validation of the HU-DBI questionnaire not properly cited

Action taken: It has been clarified that the instrument was adapted by Midolo (2023) and validated by Alvarado and Lora (2024), with these sources now properly cited. Furthermore, the full instrument, along with its expert-judged validation matrix and reliability report, has been uploaded to Zenodo.

Availability of the full instruments

Action taken: Complete versions of the OHIP-14 and HU-DBI (Spanish version) are now publicly available on Zenodo, including the validation matrices, internal reliability analysis, and the anonymized database.

Database and statistical results:

https://doi.org/10.5281/zenodo.14847738

Methodological annex with instruments and validation:

https://doi.org/10.5281/zenodo.15236712

Absence of confidence intervals and fit indicators (pseudo R²)

Action taken: Confidence intervals (95% CI) and Nagelkerke's pseudo R² values have been included in the results section and respective tables.

Causal language in the abstract and conclusions

Action taken: The language used was carefully revised, replacing all causal expressions with associative or relational formulations, consistent with the correlational cross-sectional design of the study.

Reference to Cruzado et al. (2024)

Action taken: This reference has been removed, as it was not cited in the text and does not appear in the final list of references.

 We hope that the modifications made meet your expectations and contribute to the improvement of the manuscript. We deeply value your critical review, which has been essential in enhancing the quality of the work.

Sincerely,

Miryam Griselda Lora Loza

Corresponding Author

 Lora Loza mlora@ucv.edu.pe La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: None declared.

 29 5 2025

Dear Dr. Haslinda Ramli,

We sincerely appreciate your thoughtful review and constructive comments. In response to your recommendations, we have revised the manuscript as follows:

Title Adjustment: The term "impact" was replaced with "relationship" to more accurately reflect the correlational nature of the study, avoiding causal implications inconsistent with our cross-sectional design.

Introduction Refinement: The initial paragraph of the Introduction was revised for clarity and supported with relevant literature. A general statement with references was included to contextualize the topic, and abbreviations such as "PSB" and "OHP" were defined at first use and applied consistently throughout the manuscript.

Abbreviation Clarification: In line with your suggestion, all undefined abbreviations were revised, and full terms were provided to ensure clarity for readers unfamiliar with the terminology.

 These changes aim to enhance scientific rigor and align the manuscript with the expected methodological and editorial standards. Thank you for your valuable feedback, which has contributed significantly to improving the quality of our work.

Kind regards,

Miryam Griselda Lora Loza

Corresponding Author

 Lora Loza mlora@ucv.edu.pe La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: The authors declare that there are no competing interests.

 4 7 2025

Manuscript Title: Association between Oral Health Perception and Oral Health-Related Quality of Life among Hospital Staff

Corresponding Author: Dr. Miryam Griselda Lora Loza

Date: July 4, 2025

We sincerely thank Reviewer 2, Dr. Haslinda Ramli, for her insightful and constructive comments. Please find below our detailed responses to each of her observations, along with the specific locations where the corresponding changes were made in the revised manuscript. All modifications are clearly highlighted in the tracked version.

1. Title – Use of "impact" implies causality

Comment:

The use of “impact” in the title and throughout the manuscript suggests a causal relationship, which is not supported by the cross-sectional design.

Response:

Thank you for this valuable observation. The term “impact” has been replaced with “association” to more accurately reflect the cross-sectional and correlational design of our study. The new title is:

“Association between Oral Health Perception and Oral Health-Related Quality of Life among Hospital Staff.”

    Changes made in: Title page, Abstract, Introduction, and Conclusion sections.

 2. Introduction – First sentence implies causality and lacks citation

Comment:

The opening sentence of the Introduction should avoid implying causation and must be supported by references.

Response:

We have rewritten the sentence to avoid causal language and included a reference from the World Health Organization (2022) Global Oral Health Report. The revised sentence now reads:

“Hospital staff’s perception of their oral health is associated with their overall oral health-related well-being (WHO, 2022).”

Changes made in: Introduction, first paragraph.

 3. Abbreviation inconsistency

Comment:

Please clarify the consistent use of abbreviations such as OHP, OHRQoL, and avoid unnecessary acronyms like PSB.

Response:

We reviewed the entire manuscript and standardized all abbreviations. Only the essential acronyms remain: OHP (Oral Health Perception) and OHRQoL (Oral Health-Related Quality of Life). All others, including PSB, were removed or clarified at first mention.

      Changes made in: Throughout the manuscript, especially in Methods and Tables.

4. OHIP-14 classification – Categorical scores require source

Comment:

The use of qualitative classifications for OHIP-14 (e.g., excellent, poor) needs validation or removal.

Response:

We agree with the reviewer’s concern. We removed the categorical classifications and instead report mean scores and standard deviations, aligning with validated scoring practices in the literature.

Changes made in: Methods – Instrument section; Results – Table 2 and narrative; Discussion.

 5. HU-DBI instrument – Invalid reference

Comment:

The validation reference for the HU-DBI (Cruzado et al., 2024) is invalid or unavailable.

Response:

The incorrect reference has been removed. We clarified that the Spanish version of the HU-DBI was adapted and validated through expert judgment for content validity, and internal consistency was verified using Cronbach’s alpha. Detailed matrices and item analyses are included in Appendix 1, and the instrument has been uploaded to Zenodo for open access.

  Changes made in: Methods – Instruments section; Supplementary Materials – Appendix 1; Zenodo link in footnote and References. DOI: https://doi.org/10.5281/zenodo.15236712.

 6. Sample size and generalization

Comment:

Please explain the rationale for the sample size and the generalizability of findings.

Response:

A detailed explanation has been added. The sample size was calculated using G*Power (ρ = 0.30, α = 0.05, power = 0.80), requiring a minimum of 67 participants. We enrolled 72. Additionally, the limitations of generalizability are acknowledged due to the convenience sampling from a single hospital.

     Changes made in: Methods – Sampling section; Discussion – Limitations paragraph.

7. Confidence intervals in results

Comment:

Include 95% confidence intervals in correlation and regression results.

Response:

The Results section now reports 95% confidence intervals for Spearman’s correlations and Nagelkerke’s pseudo R² estimates. This improves statistical transparency and interpretability.

Changes made in: Results section – Table 3 and narrative.

8. Clarity of language

Comment:

Improve language clarity and avoid overgeneralization.

Response:

The manuscript has undergone a comprehensive language review using Grammarly Premium, ensuring clarity, precision, and academic tone. Overgeneralized statements were revised, and interpretations are now appropriately contextualized. The manuscript adheres to the STROBE guidelines for observational studies.

Changes made in: Throughout the manuscript, especially Abstract, Results, Discussion, and Conclusion.

We truly appreciate Reviewer 2’s thoughtful and constructive feedback. Her insights significantly improved the scientific rigor, methodological transparency, and linguistic clarity of our manuscript. We are grateful for the opportunity to revise our work accordingly.

Respectfully,

Dr. Miryam Griselda Lora Loza

On behalf of all co-authors

 10.5256/f1000research.177142.r368811 Reviewer response for version 1 Asiri Faris Yahya I 1 Referee https://orcid.org/0000-0002-5802-2144 King Faisal University, Al-Ahsa, Saudi Arabia

Competing interests: No competing interests were disclosed.

 31 3 2025 Copyright: © 2025 Asiri FYI 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

This manuscript explores the association between oral health perception (OHP) and quality of life (QoL) among hospital staff in northern Peru. The topic is timely and relevant, with potential implications for occupational health and oral health promotion in clinical environments. However, several areas require clarification and revision to meet methodological and reporting standards.

1. Introduction and Use of Literature

The manuscript references global challenges in oral health but supports several key claims using regionally limited or non-peer-reviewed sources. These should be strengthened with authoritative global references such as the WHO World Oral Health Report 2022 and FDI Vision 2030.

Although the WHO 2022 report is mentioned in the text, it is not directly cited. This should be corrected.

The manuscript references multiple SDGs beyond SDG 3 (e.g., SDG 6, 10, 11) without explaining their relevance. These references should be substantiated with literature or omitted.

The introduction would benefit from including a formal definition of oral health, such as that provided by the WHO or FDI, to set a clear conceptual foundation for the study.

2. Methodological Issues

The study is described as “correlational–causal,” and the results section repeatedly uses causal language (e.g., “impact,” “influence”). However, the cross-sectional design precludes causal inference. The language should be revised to reflect associative relationships.

The manuscript lacks a sample size justification or power analysis. Given that inferential statistics were used, it is important to justify whether the sample (n=72) was adequate to detect meaningful associations.

3. Instruments and Transparency

The classification of OHIP-14 results into categories such as “excellent,” “average,” and “poor” is not part of the original instrument. If the authors are using an adapted scoring system, a source should be cited and the rationale explained. Otherwise, the standard scoring system should be used.

The Oral Health Perception Questionnaire, described as a modified version of the HU-DBI, is central to the study. However, the cited validation by Cruzado et al. (2024) is not found in the reference list.

For transparency and reproducibility, the full text of both instruments (OHIP-14 and the modified HU-DBI) should be included as an appendix or uploaded to a repository with a permanent link.

4. Statistical Reporting and Interpretation

The statistical tests used (Spearman correlation and ordinal logistic regression) are appropriate given the data distribution. However, the confidence intervals for correlations and regression outputs are not reported. Including CIs would help readers assess the precision of estimates.

Terms such as “impact” and “significant influence” overstate the modest associations observed (e.g., r = 0.391). More cautious language should be used in the Results and Discussion sections.

5. Discussion and Conclusion

The discussion and conclusions sections overstate the implications of the findings. Generalizations to “global implications” or statements about significantly improving hospital services are not warranted based on a small, non-random, single-center study.

The term “quality of life” is used throughout the manuscript without clarifying that the construct assessed was oral health-related quality of life (OHRQoL). This should be clarified to avoid misinterpretation.

6. References

Key references are missing, including the WHO World Oral Health Report 2022, and the Cruzado et al. (2024) validation paper. These should be added.

Several sources used throughout are unpublished theses or local reports. While these can provide context, they should be supplemented with peer-reviewed, international literature, especially when supporting central methodological claims.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Oral Health Research, Dental Public Health, Oral Epidemiology, Special Care Dentistry, Oral Health-Related Quality of Life, Health Promotion

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Lora Loza mlora@ucv.edu.pe La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed

 2 4 2025

Dear Reviewer,

We sincerely appreciate the valuable comments and suggestions made regarding our manuscript entitled "Impact of Oral Health Perception on the Quality of Life of Hospital Staff". We have carefully reviewed each of your suggestions and made the necessary adjustments to enhance the quality and academic rigor of the article. Below, we present our detailed responses to your observations.

1. Introduction and Use of Literature:

We appreciate your suggestion to strengthen the theoretical foundation with global references. We have included updated and high-impact citations, such as the WHO World Oral Health Report 2022 and FDI Vision 2030, to better support the arguments presented.

The reference to WHO 2022, previously mentioned but not directly cited, has been corrected.

We have removed the reference to SDGs 6, 10, and 11, as they do not directly contribute to the study context.

Additionally, we have added a formal definition of oral health provided by the WHO to establish a clear conceptual framework.

 2. Methodological Issues:

We acknowledge the inappropriate use of causal terms such as "impact" and "influence" within the context of a correlational design. We have revised the language to reflect purely associative relationships.

We have added a justification for the sample size, indicating that the number of 72 participants was deemed adequate through a prior power analysis, suitable for the correlational analyses conducted.

 3. Instruments and Transparency:

We appreciate the observation regarding the classification of OHIP-14. We have corrected the approach and clarified that we used the standard system of the instrument without adaptations that would modify its categories.

Regarding the reference to Cruzado et al. (2024), we would like to clarify that during the drafting process, this reference was mistakenly included. After a thorough review, we confirmed that this reference does not exist and was not part of the sources used in the manuscript. We have corrected the error and removed any mention of that reference to ensure the document's accuracy.

Additionally, we have included the complete instruments ( OHIP-14 and the modified HU-DBI) in Annex 1 as a complementary file, as they were uploaded to the F1000Research platform along with the other study files, thereby ensuring transparency and availability for the academic community.

 4. Statistical Reporting and Interpretation:

We have added the corresponding confidence intervals (CIs) for the correlations and regressions presented to improve the precision of the results interpretation.

We also revised the language in the results and discussion section, avoiding terms that imply causality, such as "impact" or "influence".

 5. Discussion and Conclusion:

We adjusted the tone of the discussion to avoid generalizations that are not justified, considering the sample size and the specific context of the study. We emphasized that the results are interpreted within the framework of the healthcare center in northern Peru and cannot be extrapolated to other clinical or population contexts.

Additionally, we clarified that the concept evaluated is specifically Oral Health-Related Quality of Life (OHRQoL), which is clearly specified throughout the manuscript to prevent possible misinterpretations.

 6. References:

We have added the key references suggested, including the WHO World Oral Health Report 2022 and Vision 2030: Delivering Optimal Oral Health for All.

Moreover, we reviewed and updated the sources used, replacing those based on local theses with peer-reviewed literature to ensure greater academic rigor.

Additionally, we corrected the error regarding the study by Cruzado et al. (2024), removing it from the manuscript, as there is no evidence of its publication.

 We once again appreciate your dedication to reviewing our manuscript. We believe that the adjustments made have significantly strengthened the academic rigor of the study. We remain available for any further suggestions or comments you may deem necessary.

Sincerely,

Miryam Griselda Lora Loza and co-authors.

Lora Loza mlora@ucv.edu.pe La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

 21 4 2025

Dear Reviewer,

We sincerely appreciate your thorough review and constructive feedback on our manuscript. Below we detail how each of your observations has been addressed in the revised version:

Use of Literature and International Sources

➤ Action taken: We expanded the literature review by integrating key international sources, including the WHO World Oral Health Report 2022, FDI Vision 2030, UNESCO, and UNDP documents to provide a stronger global perspective on oral health policy and inequality.

Definition of Oral Health

➤ Action taken: The WHO's formal definition of oral health has been incorporated in the Introduction to frame the central concept more precisely.

Use of the term “correlational-causal”

➤ Action taken: The term was completely removed. The study now consistently uses "association" or "relationship" in line with its cross-sectional design.

Sample Size Justification

➤ Action taken: We added a justification using G*Power software (effect size ρ = 0.30, α = 0.05, power = 0.80), which supports the adequacy of the sample size (n = 72).

Availability of Full Instruments

➤ Action taken: The full versions of the OHIP-14 and HU-DBI questionnaires (Spanish versions), along with the expert validation matrix and reliability metrics, have been uploaded to Zenodo. Links:

Dataset: https://doi.org/10.5281/zenodo.14847738

Methodological annex: https://doi.org/10.5281/zenodo.15236712

Overstatement and Global Generalization

➤ Action taken: We revised the Discussion and Conclusion to better acknowledge methodological limitations and avoid overgeneralizing findings beyond the local context.

Clarification between General QoL and OHRQoL

➤ Action taken: The construct of Oral Health-Related Quality of Life (OHRQoL) has been explicitly defined and distinguished from general quality of life (QoL), reinforcing its role as the dependent variable.

 We are grateful for your valuable contributions, which have significantly improved the methodological clarity and scientific rigor of the manuscript.

Sincerely,

Miryam Griselda Lora Loza

(Corresponding Author)

 Lora Loza mlora@ucv.edu.pe La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

 23 4 2025

Dear Reviewer,

Faris Yahya I. Asiri

King Faisal University, Saudi Arabia

We are sincerely grateful for your thorough review and constructive recommendations. Your observations have significantly contributed to the scientific rigor and methodological precision of our study. Below, we detail our responses to each point raised:

Use of Literature and International Sources

➤ Action taken: We expanded the literature review by integrating key international references, including the WHO World Oral Health Report 2022, FDI Vision 2030, UNESCO, and UNDP. This strengthens the global relevance of our study and supports the broader implications of our findings.

Definition of Oral Health

➤ Action taken: The WHO's formal definition of oral health was incorporated into the Introduction to reinforce the conceptual framework of the study.

Use of the term “correlational-causal”

➤ Action taken: We completely removed the term "correlational-causal" from the manuscript. Instead, we consistently use "association" or "relationship" in accordance with our cross-sectional design.

Sample Size Justification

➤ Action taken: We added a sample size justification using GPower software (effect size ρ = 0.30, α = 0.05, power = 80%), supporting the adequacy of the chosen sample (n = 72).

Availability of Full Instruments

➤ Action taken: The complete versions of the OHIP-14 and HU-DBI (Spanish version) were uploaded to Zenodo, along with their validation matrices and reliability reports.

Dataset: https://doi.org/10.5281/zenodo.14847738

Methodological Annex: https://doi.org/10.5281/zenodo.15236712

Overstatement and Global Generalization

➤ Action taken: We revised the Discussion and Conclusion sections to avoid overgeneralizing results. We emphasized the local scope and acknowledged methodological limitations.

Clarification between General QoL and OHRQoL

➤ Action taken: We explicitly distinguished Oral Health-Related Quality of Life (OHRQoL) from general Quality of Life (QoL), clarifying its role as the dependent variable in our analysis.

Title Modification

➤ Action taken: In response to your and Reviewer 1’s suggestions, the original title “Impact of oral health perception on quality of life” was revised to:

“Relationship between the perception of oral health and the quality of life of hospital staff”,

in order to better reflect the non-causal, correlational nature of the study.

 We trust these revisions meet your expectations and contribute to the improved quality and clarity of the manuscript. Once again, we thank you for your valuable insights and support.

Sincerely,

Miryam Griselda Lora Loza

(Corresponding Author)

 Lora Loza mlora@ucv.edu.pe La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: The authors declare that there are no competing interests.

 4 7 2025

Manuscript Title: Association between Oral Health Perception and Oral Health-Related Quality of Life among Hospital Staff

Corresponding Author: Dr. Miryam Griselda Lora Loza

Date: July 4, 2025

We sincerely thank Reviewer 1, Dr. Faris Yahya I. Asiri, for his constructive and thoughtful observations. Below, we provide detailed responses to each of his comments, along with the specific sections where changes were made in the revised manuscript. All edits are clearly marked in the tracked version.

1. Study objectives and rationale – Clarify the purpose and design

Comment:

The objective of the study and the rationale need to be more clearly presented in the introduction and methods.

Response:

We appreciate this valuable observation. The objective was reformulated to explicitly state that the study aims to examine the association between oral health perception and oral health-related quality of life (OHRQoL) among hospital staff. We also clarified the study design as correlational and cross-sectional in both the Introduction and the Methods sections.

Changes made in: Introduction (last paragraph), Methods – Design subsection.

2. Sampling method and population – Explain selection criteria

Comment:

Please provide more details about the population selection and inclusion/exclusion criteria.

Response:

We added detailed information about the inclusion and exclusion criteria and specified that the sample was selected by non-probabilistic convenience sampling from staff working at a level II hospital in northern Peru. The rationale for this selection was also explained.

Changes made in: Methods – Population and Sampling section.

3. Instruments – Provide psychometric information

Comment:

More information is needed on the validity and reliability of the instruments used.

Response:

We provided complete psychometric information for both the OHIP-14 and HU-DBI instruments. The OHIP-14 has been widely validated in Spanish-speaking populations. For the HU-DBI, we clarified that its Spanish version was adapted through expert judgment for content validity, and internal consistency was calculated using Cronbach’s alpha. All related evidence and matrices are now available in Appendix 1 and open-access via Zenodo.

Changes made in: Methods – Instruments subsection; Supplementary Appendix 1; References (Zenodo DOI: https://doi.org/10.5281/zenodo.15236712).

4. Statistical analysis – More clarity needed

Comment:

Clarify how the variables were analyzed and justify the tests used.

Response:

We improved the description of the statistical analysis. We explained the use of Spearman’s correlation due to non-normal data distribution, and logistic regression to explore the association between OHP and OHRQoL domains. Confidence intervals (95%) were added to support the strength and precision of the results.

Changes made in: Methods – Data Analysis subsection; Results – Table 3 and text.

5. Interpretation of findings – Avoid causal language

Comment:

The interpretation of findings should not suggest causality in a cross-sectional design.

Response:

We revised the Discussion and Conclusion sections to avoid any causal implications, consistently using associative and correlational terminology. We acknowledge the limitations of cross-sectional studies and emphasized the need for further longitudinal research.

Changes made in: Discussion and Conclusion sections.

6. Ethical considerations – Add details on approvals

Comment:

Please confirm ethical approval and participant consent.

Response:

We added that the study received ethical approval from the Institutional Ethics Committee of Universidad César Vallejo (Approval No. 007-2025-CEI), and that written informed consent was obtained from all participants in accordance with the Declaration of Helsinki.

Changes made in: Methods – Ethical Considerations subsection.

We thank Reviewer 1 for his invaluable contributions. His remarks allowed us to strengthen the scientific robustness, ethical transparency, and methodological consistency of our study.

Respectfully,

Dr. Miryam Griselda Lora Loza

On behalf of all co-authors

10.5256/f1000research.177142.r371448 Reviewer response for version 1 John Mike T 1 Referee University of Minnesota, Minneapolis, USA

Competing interests: No competing interests were disclosed.

 24 3 2025 Copyright: © 2025 John MT 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation reject

The manuscript “Impact of oral health perception on the quality of life of hospital staff” aimed to “analyze the relationship between the QoL and the PSB of the staff of a level II-1 hospital, located in the north of Peru, taking into account its dimensions and interactions. The research aims to provide evidence to design strategies that promote the well-being of health personnel and optimize the quality of care provided to patients.”

The topic is interesting and relevant, but the methodology is flawed. The researchers are interested to “provide evidence to design strategies that promote the well-being of health personnel and optimize the quality of care provided to patients.” However, the authors performed a cross-sectional study, and this study design is not able to derive “evidence” for “promotion strategies.” Such evidence can only be derived from longitudinal studies.

Is the work clearly and accurately presented and does it cite the current literature? – No

The authors are not aware that OHRQoL measured by OHIP does not have 7 dimensions. OHRQoL has four dimensions (John MT, 2020 [Ref-1]). 

The authors are not aware of the recent scoring recommendations for OHIP (John MT., 2022 [Ref-2]).

Is the study design appropriate and is the work technically sound? – No

The authors performed a cross-sectional study when a longitudinal study would have been necessary to answer the research question.

Are sufficient details of methods and analysis provided to allow replication by others? – No

The central study outcome is oral health-related quality of life measured by OHIP-14.  The authors provided the following information: “Regarding the instruments, the Quality of Life (QoL) Questionnaire was used, originally designed by Slade and Spencer in 1994, adapted by Espinoza in 2017, and updated and validated in 2024 by Cruzado, Alvarado, and Lora. Loza. This questionnaire includes 14 items organized into 7 dimensions (Functional limitation, Physical pain, Psychological discomfort, Physical disabilities, Psychological disabilities, Social disability, and Disability), with 2 items per dimension. A 5-point Likert scale was applied (0 = never, 4 = very frequently), the results of which were classified into three categories: excellent (0-2 points), average (3-9 points), and poor quality of life (10 points or more).”

The authors provided in the reference list a reference to Slade and Spencer and to Espinoza; however, a reference to “updated and validated in 2024 by Cruzado, Alvarado, and Lora. Loza” is missing. Therefore, it is not clear what was measured, especially, because the authors use an item response scale ranging from “never” to “very frequently,” which is not OHIP’s original response format.

If applicable, is the statistical analysis and its interpretation appropriate? – No

For many results, e.g., “significant association between quality of life and oral health perception (Rho=0.391, p<0.05)”, the authors only provided point estimates. Confidence intervals around point estimates describe the uncertainty around the results. In this study with N=72, this uncertainty is substantial. Calculating a confidence interval according to https://www.statskingdom.com/correlation-confidence-interval-calculator.html reveals that correlations as small as 0.18 and as large as 0.57 are compatible with the study. While the observed correlation of 0.391 is statistically significant, i.e., it can be differentiated from 0, the observed “medium” size correlation could be “small” or “large” when the study would be repeated, indicating that not much can be learned from the study.

Are the conclusions drawn adequately supported by the results? – No

The authors concluded “The link between quality of life and the perception of oral health in hospital staff emphasizes the need to implement comprehensive strategies that optimize their well-being and work performance, contributing significantly to improving hospital services.”

First, the authors make a statement about quality of life. However, quality of life (a construct that entails environment, safety, freedom etc.) was not measured. ORAL HEALTH-RELATED quality of life was measured.

Second, the magnitude of the link between oral health-related quality of life and perception of oral health is not clear. It could be small, i.e., not clinically relevant.

Third, “the need to implement comprehensive strategies” is not supported by the cross-sectional study design.

Is the work clearly and accurately presented and does it cite the current literature?

No

If applicable, is the statistical analysis and its interpretation appropriate?

No

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

No

Are the conclusions drawn adequately supported by the results?

No

Are sufficient details of methods and analysis provided to allow replication by others?

No

Reviewer Expertise:

oral health-related quality of life

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

References : Foundations of oral health-related quality of life. J Oral Rehabil .2020; 10.1111/joor.13040 32658317 10.1111/joor.13040 : STANDARDIZATION OF DENTAL PATIENT-REPORTED OUTCOMES MEASUREMENT USING OHIP-5 - VALIDATION OF "RECOMMENDATIONS FOR USE AND SCORING OF ORAL HEALTH IMPACT PROFILE VERSIONS". J Evid Based Dent Pract .2022;22(1S) : 10.1016/j.jebdp.2021.101645 101645 35063174 10.1016/j.jebdp.2021.101645 Lora Loza mlora@ucv.edu.pe La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: None declared.

 29 5 2025

Dear Dr. Mike T. John,

Warm greetings.

I wish to express my deepest gratitude for the time and expertise you invested in reviewing our manuscript. Your thorough and constructive feedback has been instrumental in guiding substantial improvements to our study entitled:

“Relationship between oral health perception and quality of life in hospital staff.”

I humbly apologize for not responding sooner to your detailed review. At the time, I was not yet familiar with the F1000Research platform and unfortunately overlooked your comments. Now that I have a better understanding of the system, I wish to respectfully inform you that all your major observations have now been addressed in the revised version, including:

Title and Causal Language: The word “impact” was replaced with “relationship”, and causal or prescriptive expressions were carefully revised to remain within the scope of a correlational, cross-sectional design.

Clarification of OHIP-14 Scoring: We corrected the dimensional interpretation and cited John (2020, 2022) for standard scoring guidance. The questionnaire was reformulated to respect international standards and now includes proper acknowledgment of the four-dimensional structure of OHRQoL.

Psychometric Validity: We uploaded the full instruments (OHIP-14 and HU-DBI) including psychometric data to Zenodo, ensuring full transparency and replicability.

Statistical Reporting: We added confidence intervals for correlation coefficients and justified the sample size using G*Power, as well as reporting Nagelkerke’s pseudo R² to better interpret the logistic regression outcomes.

Terminology: We replaced the term “quality of life” with “oral health-related quality of life” throughout the manuscript to maintain conceptual accuracy.

Conclusions Revised: We rephrased our conclusions to reflect the statistical scope and limitations of a cross-sectional study, without suggesting implementation of strategies not directly derived from the design.

 These modifications were made not only out of respect for your review, but also in appreciation for your high standards in the field of oral health-related quality of life research. We believe that the manuscript now meets the criteria for methodological and scientific integrity and would be deeply honored if you could consider revisiting the updated version.

Please feel free to share any further suggestions—we remain open and grateful to continue improving.

With highest respect and appreciation,

Miryam Griselda Lora Loza

Corresponding Author

Lora Loza mlora@ucv.edu.pe La Libertad, Universidad Cesar Vallejo Facultad de Ciencias Medicas, Trujillo /Trujillo, Trujillo, Peru

Competing interests: No competing interests were disclosed.

 12 11 2025

Dear Dr. John, as a brief update: Version 5 integrates your core recommendations—OHIP conceptualization (four dimensions) and scoring aligned with John (2020; 2022), non-causal language for a cross-sectional design, 95% CIs added to correlations, and instruments/data shared openly. We appreciate your foundational input and would be grateful for any further advice. All changes are visible in V5 (tracked).