The relationship between regional socioeconomic position and oral health behavior: A multilevel approach analysis

Cheoul-Sin Kim; Sun-Young Han; Chul-Woung Kim

doi:10.11149/jkaoh.2013.37.4.208

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Kim, Han, and Kim: The relationship between regional socioeconomic position and oral health behavior: A multilevel approach analysis

Original Article

J Korean Acad Oral Health 2013;37(4):208-215.

Published online: 12 December 2013

DOI: https://doi.org/10.11149/jkaoh.2013.37.4.208

The relationship between regional socioeconomic position and oral health behavior: A multilevel approach analysis

Cheoul-Sin Kim¹, Sun-Young Han¹, Chul-Woung Kim²

¹Research Institute for Dental Care Policy, Korean Dental Association, Seoul, Korea

²Department of Preventive Medicine, Chungnam National University, Daejeon, Korea

Corresponding Author: Chul-Woung Kim Department of Preventive Medicine, Chungnam National University, 282 Munhwa-ro, Jung-gu, Daejeon 301-721, Korea Tel: +82-42-580-8268 Fax: +82-42-580-8439 E-mail: woung2@gmail.com

Received 20 August 2013 Revised 6 November 2013 Accepted 25 November 2013

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objectives

This study was conducted to identify discrepancies in oral health behaviors among communities in cities, counties, and districts (si, gun, and gu administrative divisions of South Korea) and to determine their correlations with socioeconomic status, examined in terms of the social deprivation index.

Methods

Data for 220,258 individuals, covering 247 communities, were extracted from a 2008 community health survey, and the frequency of brushing the teeth after lunch, flossing and interdental brushing was calculated and analyzed. Considering the characteristics of the data collected at individual and regional levels, a multilevel random-intercept logistic regression model was used for the analysis.

Results

A regional-level discrepancy was found in after-lunch brushing and the use of auxiliary oral hygiene items, with interclass correlations of 0.03 and 0.04, respectively. In particular, the odds ratio of using auxiliary oral hygiene items in the communities with the lowest socioeconomic status was as low as 0.49, compared to the highest level, thus demonstrating a conspicuous intercommunity difference.

Conclusions

The regional-level correlation between socioeconomic status and oral health behaviors indicates the need for the establishment of oral health-related intervention policies based on community characteristics.

Keywords: Multilevel analysis, Oral health behavior, Socioeconomic position

References

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Table 1.

The variables of this study

Classification	The contents of variables
Independent variables Individual level	Sex: male or female Age: over the age 19 years, classified into 6 groups Income (monthly average equivalent household income): classified into 5 groups* Economic activity: active or inactive Cohabitation with spouse: yes or no Education: uneducated, ≤ elementary school, ≤ high school, university ≤
Regional level	Socioeconomic level (Regional deprivation index for Korean): Classified into 5 groups^† Dental service level: Number of dentists per 100,000 population Social capital level: Number of volunteers per 1,000 population
Dependent variables	Tooth brushing after lunch Usage of dental floss and interdental brush

*Low: ≤495,000; 495,000<middle-low≤894,000; 894,000<middle ≤1,414,000; 1,414,000<middle-high≤2,000,000; high: >2,000,000 (unit: won).

^† Low>1.03516; 0.16510<middle-low≤1.03516; ―0.43748<middle≤0.16510; ―0.87953<middle-high≤―0.43748; high≤―0.87953.

Table 2.

Oral health behavior: individual level

	N	Tooth brushing after lunch		Usage of dental floss and interdental brush
	N	%	P	%	P
Total		47.5		16.1
Age (yrs)
19-29	26,074	56.7	0.000	14.3	0.000
30-39	40,047	56.5		21.8
40-49	44,837	50.0		20.0
50-59	39,078	39.9		15.7
60-69	35,766	31.9		9.6
≥70	34,456	27.5		4.1
Sex
Male	101,358	42.3	0.000	12.8	0.000
Female	118,900	52.5		19.4
Education
Uneducated	22,562	24.0	0.000	2.3	0.000
≤Elementary school	42,566	27.9		5.3
≤High school	92,624	44.3		14.2
University≤	62,435	58.8		22.7
Cohabitation with spouse
Cohabitation	151,447	47.3	0.000	18.3	0.000
Not cohabitation	37,101	36.1		9.8
Not answer	882	44.7		11.0
Income
Low	36,712	32.0	0.000	6.2	0.000
Middle-low	34,542	39.8		10.8
Middle	37,498	46.2		14.5
Middle-high	37,347	51.9		18.3
High	35,911	56.8		23.8
Economic activity			0.000		0.300
Activity	132,811	50.8		16.2
Inactivity	87,389	42.4		16.0

Complex sample analysis (chi-square test), weighted %.

Table 3.

Oral health behavior: regional socioeconomic level

Regional socioeconomic level	N (regions)	N (individuals)	Tooth brushing after lunch		Usage of dental floss and interdental brush
Regional socioeconomic level	N (regions)	N (individuals)	%	P	%	P
Total			47.5		16.1
High	49	46,021	50.2	0.000	21.0	0.000
Middle-high	50	45,769	48.3		15.6
Middle	49	46,371	47.1		13.8
Middle-low	50	46,022	40.4		9.7
Low	49	45,523	37.9		6.6

Complex sample analysis (Chi-square test), weighted %.

Table 4.

Multilevel logistic regression analysis of oral health behaviors

Fixed effect	Tooth brushing after lunch		Usage of dental floss and interdental brush
	Model 2: final model		Model 2: final model
	Odds ratio	95% CI	Odds ratio	95% CI
γ00	0.81	0.74-0.90	0.21	0.19-0.25
Regional level
γ₀₃No. of volunteers	1.00	1.00-1.00	1.00	1.00-1.00
γ₀₂No. of dentists	1.02	0.91-1.14	1.28	0.99-1.66
γ₀₁Socioeconomic level
Middle-high	0.99	0.88-1.11	0.79	0.69-0.91
Middle	0.97	0.86-1.09	0.68	0.59-0.78
Middle-low	0.90	0.80-1.01	0.61	0.52-0.72
Low	0.95	0.82-1.10	0.49	0.42-0.58
Individual level
γ₁₀Sex	1.66	1.61-1.71	1.75	1.69-1.82
γ₂₀Age	0.98	0.98-0.99	0.99	0.99-0.99
γ₃₀Economic activity	0.96	0.92-1.01	1.14	1.09-1.18
γ₄₀Income
Low	0.66	0.62-0.70	0.47	0.43-0.52
Middle-low	0.67	0.64-0.71	0.60	0.56-0.65
Middle	0.72	0.69-0.76	0.71	0.67-0.75
Middle-high	0.86	0.87-0.90	0.85	0.80-0.89
γ₅₀Education
Uneducated	0.29	0.26-0.31	0.09	0.07-0.11
≤Elementary school	0.33	0.31-0.35	0.19	0.17-0.21
≤High school	0.58	0.56-0.60	0.53	0.50-0.55
γ₆₀Cohabitation with spouse	1.00	0.96-1.03	0.84	0.79-0.89
Model 1 : null model γ₀₀	0.71	0.67-0.75	0.12	0.11-0.13

Random effect	Tooth brushing after lunch		Usage of dental floss and interdental brush
Random effect	Model 1: null model	Model 2: final model	Model 1: null model	Model 2: final model
Tau	0.17*	0.10*	0.46*	0.13*
Intra-class correlation	0.05	0.03	0.12	0.04
Deviance^†	625,499.80	444,691.00	623,078.40	435,605.20
Number of parameters	2	19	2	19
Reliability	0.97	0.93	0.97	0.87

Reference category: high socioeconomic level, male, university≤, cohabitation with spouse (yes), activity (yes), high income. *P<0.01,

^† ―2LL(log likelihood).

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