Poverty, social exclusion and dental caries of 12-year-old children: a cross-sectional study in Lima, Peru
© Delgado-Angulo et al; licensee BioMed Central Ltd. 2009
Received: 20 February 2009
Accepted: 07 July 2009
Published: 07 July 2009
Socioeconomic differences in oral health have been reported in many countries. Poverty and social exclusion are two commonly used indicators of socioeconomic position in Latin America. The aim of this study was to explore the associations of poverty and social exclusion with dental caries experience in 12-year-old children.
Ninety families, with a child aged 12 years, were selected from 11 underserved communities in Lima (Peru), using a two-stage cluster sampling. Head of households were interviewed with regard to indicators of poverty and social exclusion and their children were clinically examined for dental caries. The associations of poverty and social exclusion with dental caries prevalence were tested in binary logistic regression models.
Among children in the sample, 84.5% lived in poor households and 30.0% in socially excluded families. Out of all the children, 83.3% had dental caries. Poverty and social exclusion were significantly associated with dental caries in the unadjusted models (p = 0.013 and 0.047 respectively). In the adjusted model, poverty remained significantly related to dental caries (p = 0.008), but the association between social exclusion and dental caries was no longer significant (p = 0.077). Children living in poor households were 2.25 times more likely to have dental caries (95% confidence interval: 1.24; 4.09), compared to those living in non-poor households.
There was support for an association between poverty and dental caries, but not for an association between social exclusion and dental caries in these children. Some potential explanations for these findings are discussed.
Among rich and poor countries, those people who are worse off in socioeconomic terms have worse health outcomes and higher mortality rates than those who are better off. However, it is not only the case that the poorest in society have poor health, but a gradient of ill-health and mortality exists across all socioeconomic groups [1–4]. This socioeconomic gradient has been found consistently also in different oral health measures around the world [5–10].
Poverty and social exclusion are two commonly used indicators of socioeconomic position in Latin America [11–13]. Absolute poverty refers to the lack of resources for survival and personal development as well as the necessary tools for relieving this situation [14, 15]. People are considered to be poor when they cannot satisfy their basic needs . Poverty imposes constraints on the material conditions of everyday life, by limiting access to the fundamental building blocks of health such as adequate housing, good nutrition and the opportunity to maintain optimal personal hygiene [2, 4].
On the other hand, social exclusion refers to the accumulation of disadvantages, which isolate people from integrated social and physical human development [17, 18]. Social exclusion prevents people from participating in education or training and gaining access to services and citizenship activities [18, 19]. Being excluded from the life of society and being treated as less than equal, leads to worse health and greater risks of premature death [16, 19]. Therefore, social exclusion refers not only to economic hardship, but also incorporates the process of marginalisation, that is, how individuals come to be excluded and marginalised in society [3, 15]. Hence, social exclusion adds psychosocial aspects to the debate on poverty and links social disadvantages with individual participation and the stability of society [3, 16, 19].
Poverty, the extent of relative deprivation and the processes of social exclusion in a society have a major impact on the health of populations [2, 3, 16], and this also applies to oral conditions [6, 20]. Parental socioeconomic position greatly affects the risk of dental caries in young children in both developed and developing countries [5, 7, 9, 10, 21].
According to national figures in Peru, about 40% of the population live in poverty [13, 22], however, there are no reports on the extent of social exclusion. On the other hand, Peruvian children aged 12 years have moderate levels of dental caries , with an average of 3 decayed, missing and filled teeth per child [23, 24]. Although some previous studies have explored the association between poverty and oral health in Latin-American children [21, 25, 26], there are no reports regarding the relationship of social exclusion to child oral health. The purpose of this study was to fill this gap. The study aimed, therefore, to explore the relationship between poverty, social exclusion and dental caries levels in 12-year-old Peruvian children.
Ninety families, with a child aged 12 years, were selected from the 11 underserved communities linked to the Health Centre in Zapallal Alto (Lima, Peru), using a two-stage cluster sampling. There were 156 street blocks in these communities. For the sample selection, blocks were considered as clusters and chosen with a probability proportional to their size (i.e., the number of households per block). This selection procedure guaranteed that each household had an equal probability of selection. In each selected block, all households were screened for eligibility and those with a child aged 12 years were invited to participate. The design effect, defined as the ratio between the variances of the caries prevalence for cluster and simple random sampling , was 1.10, according to the pilot study. Therefore, the number of families required to estimate a significant association between poverty and dental caries prevalence (odds ratio of 3.0) with a statistical power of 80% and a type I error of 5% was 81, but this was increased to 89 to take account of the design effect. In all ninety-one families, in 43 blocks, were invited to participate.
Ethical approval was obtained from the International Research Board at the Universidad Peruana Cayetano Heredia. Only those children who agreed to participate and whose parents signed a consent form were enrolled in the study.
Sample distribution by indicators of poverty and social exclusion
Inadequate housing (walls and ceiling not made of bricks and cement)
Overcrowded household (more than 3 persons per room)
Access to sanitation
No access to safe water supply and sewerage facilities
Access to education
Low school enrolment (1 or more children aged 6–12 not attending school)
High dependency rate (household head without secondary education, more than 2 dependants)
Distributional and material
Labour market performance (more than 12 months of unemployment)
Living standards (last decile of Proportional Deprivation Index)
Income poverty (below 50% of the mean equivalent household income)
Educational status (No vocational training)
Housing conditions (less than 1 room per person or no bath/toilet)
Residential area (feeling of insecurity and bad living conditions in neighbourhood)
Relational and participatory
Social relationships (no close friends and limited chances to contact other people)
Politics (pessimism concerning political influence and no interest in politics)
Anomie (feeling lonely or that life is too complicated)
Anxiety (depression and frightening thoughts)
Development of living conditions
Thereafter, children were dentally examined by a trained examiner (EKD), following the WHO recommendations . Dental caries was diagnosed visually at the caries into dentine threshold and recorded as the number of decayed (D), missing (M) and filled (F) teeth or DMFT index. Intra- and inter-examiner reliability values at the end of the calibration process were 0.93 and 0.85 respectively (Generalised Kappa, p < 0.001 in both cases). A second visit for testing reliability during the main study was not conducted due to logistic reasons.
The DMFT scores were dichotomised because of their skewed distribution in the sample. Children were considered as caries-free if they had a DMFT score of 0 and as having dental caries if they had a DMFT score higher than 0. Following this dichotomisation of the DMFT scores the unadjusted and adjusted associations of poverty and social exclusion with dental caries were assessed using binary logistic regression models. Study design was taken into account during the statistical analysis. Odds ratios (OR) were used to assess the strength of associations.
Ninety 12-year-old children (42 boys and 48 girls) participated in this study. The response rate was 98.9%. Of these children, 84.5% were living in poor households and 30.0% in socially excluded families. The distribution of the sample, according to each of the poverty and social exclusion indicators is shown in Table 1. The mean DMFT score was 3.93 teeth (SD: 3.72), ranging from 0 to 21 and the prevalence of dental caries was 83.3%.
Binary logistic regression models for the associations of poverty and social exclusion with dental caries prevalence in 12-year-old children (n = 90).
Poverty (1 or more unsatisfied basic needs)
Social exclusion (three domains affected)
This study examined the associations between poverty, social exclusion and dental caries of 12-year-old Peruvian children. The findings suggest that children living in poor households had more chance of having dental caries, even when account is taken of their social exclusion. However, the findings did not support an association between social exclusion and dental caries, as this association was completely attenuated when taking poverty into account. There are three potential explanations for these findings:
The first, possible explanation is that material deprivation really does have a greater impact on oral health among these children, compared to that of social exclusion. Previous research has shown the detrimental effects of being excluded from society on health. This evidence comes mainly from developed countries [4, 16]. Wilkinson has suggested that up to a certain point per capita Gross Nation Income (GNI) does matter, but that beyond a certain level of per capita GNI, material living standards are no longer the main determinant of individuals' health [32, 33], but rather income disparity between families. Although Peru has achieved sustainable economic development during the last decade, poverty levels remain as the main cause of morbidity and mortality in all age groups . Similar findings have been reported in Brazil, where areas with the lowest levels of caries experience were concentrated in regions with better profile of social conditions [21, 25]. Indeed, the mean number of persons per room in a household was the factor most strongly associated with dental caries levels . So in the case of Peru it may still be that per capita GNI may still be the main factor in the levels of 12-year-old dental caries.
A second explanation relates to the potential mediating role of social exclusion in the relationship between poverty and dental caries. Material living conditions, where children live, may affect their participation in roles, relationships, functions, rights and responsibilities implied by membership of society, which in turn might affect their oral health. This explanation is supported by the significant unadjusted associations of poverty and social exclusion with dental caries and the 8%-decrease in the odds ratio for the association between poverty and dental caries after controlling for social exclusion. However, poverty and social exclusion were not significantly related in this sample (data not shown, p = 0.376), which fails to fulfil all the four conditions required to support a mediated pathway (i.e., the explanatory variable should be significantly related to the potential mediator and the outcome, the potential mediator should be related to the outcome and the relationship between the explanatory variable and the outcome should be attenuated when controlling for the potential mediator) [34, 35]. Undoubtedly, further longitudinal studies are required to disentangle the roles of poverty and social exclusion in oral health.
The last but not least explanation relates to a certain degree of overlap between the constructs of poverty and social exclusion, as they were operationalised in this study. The assessment of the distributional and material aspects of social exclusion included indicators of long-term unemployment, income poverty, education, housing quality and neighbourhood conditions, which are strongly correlated to material deprivation, and therefore, tend to cluster around poor households . This is supported by the fact that social exclusion remained significantly associated with dental caries, while accounting for poverty, when the material domain was left out in defining social exclusion (data not shown, p = 0.040). However, material indicators are of great value for gaining insights into the correspondence between insufficient living conditions in objective terms and their subjective evaluation, and also, in the context and conditions, under which such an evaluation takes place .
From explanations to limitations – as in any study there were limitations to this study, which need to be discussed. First, the data were cross-sectional. Causality cannot be determined using a cross-sectional design. Second, although this study used a random sample with an excellent participation rate, families were not representative of the entire Peruvian child population. Thus, the present findings are not generalisable beyond the study population. Third, the sample only included families living in underserved communities, and thereby, it did not capture the entire spectrum of socioeconomic conditions in Peru. Using a sampling frame of underserved communities may have restricted the variability in the sample and the statistical power to detect associations. However, sample size was based on conventional calculations and as such adequate for the aim of this study. Therefore, further studies, using a sampling frame that includes a more varied group of households, are needed to validate these findings. Fourth, socioeconomic position was indicated by poverty and social exclusion and not by the conventional measures of education, income or occupation [14, 36]. However, the latter indicators are not reliable measures of poverty in low-income countries as they exclude other elements of deprivation [37, 38]. Fifth, ORs were used for estimation in order to keep analyses straightforward and comprehensible. Recently, there has been much interest in estimating prevalence ratios (PRs) instead of ORs, especially in studies involving common outcomes [39, 40]. However, there is still a debate about which measure to use  and what is the best approach to estimate PRs since results can be quite different depending on the method used [39, 40, 42]. Sixth, no attempt to control for oral health-related behaviours was carried out. As the aim was to assess the overall impact of socioeconomic position on dental caries levels of 12-year-old children, it was considered inappropriate to adjust for behaviours. Indeed, oral health-related behaviours are considered as merely intermediates of the relationship between socioeconomic indicators and oral health [20, 43, 44].
Children living in poor households were about twice as likely to have dental caries after accounting for social exclusion than children living in wealthier households. On the other hand, social exclusion was not related to dental caries in children when account was taken of poverty. Some explanations for these findings are: first, the impact of material deprivation on dental caries in these children, compared to that of social exclusion is real; second, the potential mediating role of social exclusion in the relationship between poverty and dental caries; and third, the overlap between some poverty and social exclusion indicators masks the contribution made by either poverty or social exclusion separately. More studies using broader sampling frames are required to confirm the present findings.
This study was sponsored by the Facultad de Estomatología Roberto Beltrán Neira at the Universidad Peruana Cayetano Heredia.
Eduardo Bernabé was supported by the Programme Alβan, the European Union Programme of High Level Scholarships for Latin America, Scholarship N° E06D1000352PE.
- Adler NE, Ostrove JM: Socioeconomic status and health: what we know and what we don't. Ann N Y Acad Sci. 1999, 896: 3-15. 10.1111/j.1749-6632.1999.tb08101.x.View ArticlePubMedGoogle Scholar
- Marmot M, Wilkinson RG, Eds: Social determinants of health. 2006, Oxford: Oxford University Press, 2Google Scholar
- Marmot M: Social determinants of health inequalities. Lancet. 2005, 365: 1099-1104.View ArticlePubMedGoogle Scholar
- CSDH: Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. 2008, Geneva: World Health OrganizationGoogle Scholar
- Watt R, Sheiham A: Inequalities in oral health: a review of the evidence and recommendations for action. Br Dent J. 1999, 187: 6-12. 10.1038/sj.bdj.4800191a.PubMedGoogle Scholar
- Locker D: Deprivation and oral health: a review. Community Dent Oral Epidemiol. 2000, 28: 161-169. 10.1034/j.1600-0528.2000.280301.x.View ArticlePubMedGoogle Scholar
- Reisine ST, Psoter W: Socioeconomic status and selected behavioral determinants as risk factors for dental caries. J Dent Educ. 2001, 65: 1009-1016.PubMedGoogle Scholar
- Hobdell MH, Oliveira ER, Bautista R, Myburgh NG, Lalloo R, Narendran S, Johnson NW: Oral diseases and socio-economic status (SES). Br Dent J. 2003, 194: 91-96. 10.1038/sj.bdj.4809882. discussion 88View ArticlePubMedGoogle Scholar
- Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C: The global burden of oral diseases and risks to oral health. Bull World Health Organ. 2005, 83: 661-669.PubMedPubMed CentralGoogle Scholar
- Lopez R, Fernandez O, Baelum V: Social gradients in periodontal diseases among adolescents. Community Dent Oral Epidemiol. 2006, 34: 184-196. 10.1111/j.1600-0528.2006.00271.x.View ArticlePubMedGoogle Scholar
- PAHO: Health Indicators: Building blocks for health situation analysis. Epidemiol Bull. 2001, 22 (4): 1-5.Google Scholar
- Gacitua E, Sojo C, Eds: Social Exclusion and Poverty Reduction in Latin America and the Caribbean. 2000, Washington DC: World BankGoogle Scholar
- PAHO: Health in the Americas. 2007, Washington DC Pan American Health OrganizationGoogle Scholar
- Krieger N, Williams DR, Moss NE: Measuring social class in US public health research: concepts, methodologies, and guidelines. Annu Rev Public Health. 1997, 18: 341-378. 10.1146/annurev.publhealth.18.1.341.View ArticlePubMedGoogle Scholar
- Mowafi M, Khawaja M: Poverty. J Epidemiol Community Health. 2005, 59: 260-264. 10.1136/jech.2004.022822.View ArticlePubMedPubMed CentralGoogle Scholar
- Wilkinson R, Marmot M, Eds: Social determinants of health: The solid facts. 2003, Copenhagen: World Health Organization, 2Google Scholar
- Berman Y, Phillips D: Indicators of social quality and social exclusion at national and community level. Soc Indic Res. 2000, 3: 329-350. 10.1023/A:1007074127144.View ArticleGoogle Scholar
- Aber JL, Gershoff ET, Brooks-Gunn J: Social exclusion of children in the U.S.: identifying potential indicators. Beyond child poverty: The social exclusion of children. Edited by: Kahn AJ, Kamerman SB. 2002, New York: Columbia University Press, 245-286.Google Scholar
- Böhnke P: Nothing left to lose? Poverty and social exclusion in comparison. Empirical evidence in Germany. 2001, Berlin: Social Science Research Center Berlin, 1-35.Google Scholar
- Sisson KL: Theoretical explanations for social inequalities in oral health. Community Dent Oral Epidemiol. 2007, 35: 81-88. 10.1111/j.1600-0528.2007.00354.x.View ArticlePubMedGoogle Scholar
- Narvai PC, Frazao P, Roncalli AG, Antunes JL: Dental caries in Brazil: decline, polarization, inequality and social exclusion. Rev Panam Salud Publica. 2006, 19: 385-393. 10.1590/S1020-49892006000600004.View ArticlePubMedGoogle Scholar
- National Household Survey. [http://www.inei.gob.pe/]
- Beltran-Aguilar ED, Estupinan-Day S, Baez R: Analysis of prevalence and trends of dental caries in the Americas between the 1970s and 1990s. Int Dent J. 1999, 49: 322-329.View ArticlePubMedGoogle Scholar
- Estupinan-Day SJ: International Perspectives and practical applications on fluorides and fluoridation. J Public Health Dent. 2004, 64: 40-43. 10.1111/j.1752-7325.2004.tb02776.x.View ArticleGoogle Scholar
- Antunes JL, Frazao P, Narvai PC, Bispo CM, Pegoretti T: Spatial analysis to identify differentials in dental needs by area-based measures. Community Dent Oral Epidemiol. 2002, 30: 133-142. 10.1034/j.1600-0528.2002.300207.x.View ArticlePubMedGoogle Scholar
- Antunes JL, Narvai PC, Nugent ZJ: Measuring inequalities in the distribution of dental caries. Community Dent Oral Epidemiol. 2004, 32: 41-48. 10.1111/j.1600-0528.2004.00125.x.View ArticlePubMedGoogle Scholar
- Skinner CJ, Holt D, Smith TMF: Analysis of complex surveys. 1989, Chichester: John Wiley & SonsGoogle Scholar
- Acquadro C, Conway K, Giroudet C, Mear I: Linguistic validation manual for patient-reported outcomes (PRO) instruments. 2004, Lyon: Mapi Research InstituteGoogle Scholar
- Guillemin F, Bombardier C, Beaton D: Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. J Clin Epidemiol. 1993, 46: 1417-1432. 10.1016/0895-4356(93)90142-N.View ArticlePubMedGoogle Scholar
- Beaton DE, Bombardier C, Guillemin F, Ferraz MB: Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000, 25: 3186-3191. 10.1097/00007632-200012150-00014.View ArticlePubMedGoogle Scholar
- WHO: Oral Health Surveys: basic methods. 1997, Ginebra: World Health Organization, 4Google Scholar
- Wilkinson RG: Unhealthy societies: the afflictions of inequalities. 1996, London: Routledge, 1View ArticleGoogle Scholar
- Wilkinson RG, Pickett KE: The problems of relative deprivation: why some societies do better than others. Soc Sci Med. 2007, 65: 1965-1978. 10.1016/j.socscimed.2007.05.041.View ArticlePubMedGoogle Scholar
- Baron RM, Kenny DA: The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986, 51: 1173-1182. 10.1037/0022-3518.104.22.1683.View ArticlePubMedGoogle Scholar
- MacKinnon DP, Fairchild AJ, Fritz MS: Mediation analysis. Annu Rev Psychol. 2007, 58: 593-614. 10.1146/annurev.psych.58.110405.085542.View ArticlePubMedPubMed CentralGoogle Scholar
- Galobardes B, Lynch J, Smith GD: Measuring socioeconomic position in health research. Br Med Bull. 2007, 81–82: 21-37. 10.1093/bmb/ldm001.View ArticlePubMedGoogle Scholar
- Pena R, Wall S, Persson LA: The effect of poverty, social inequity, and maternal education on infant mortality in Nicaragua, 1988–1993. Am J Public Health. 2000, 90: 64-69. 10.2105/AJPH.90.1.64.View ArticlePubMedPubMed CentralGoogle Scholar
- Lindelow M: Sometimes more equal than others: how health inequalities depend on the choice of welfare indicator. Health Econ. 2006, 15: 263-279. 10.1002/hec.1058.View ArticlePubMedGoogle Scholar
- Barros AJ, Hirakata VN: Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003, 3: 21-10.1186/1471-2288-3-21.View ArticlePubMedPubMed CentralGoogle Scholar
- Petersen MR, Deddens JA: A comparison of two methods for estimating prevalence ratios. BMC Med Res Methodol. 2008, 8: 9-10.1186/1471-2288-8-9.View ArticlePubMedPubMed CentralGoogle Scholar
- Pearce N: Effect measures in prevalence studies. Environ Health Perspect. 2004, 112: 1047-1050.View ArticlePubMedPubMed CentralGoogle Scholar
- Deddens JA, Petersen MR: Approaches for estimating prevalence ratios. Occup Environ Med. 2008, 65: 501-486. 10.1136/oem.2007.034777.View ArticleGoogle Scholar
- Sanders AE, Spencer AJ, Slade GD: Evaluating the role of dental behaviour in oral health inequalities. Community Dent Oral Epidemiol. 2006, 34: 71-79. 10.1111/j.1600-0528.2006.00261.x.View ArticlePubMedGoogle Scholar
- Sabbah W, Tsakos G, Chandola T, Sheiham A, Watt RG: Social gradients in oral and general health. J Dent Res. 2007, 86: 992-996. 10.1177/154405910708601014.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6831/9/16/prepub