https://userupload.net/nzqpb47zspb8 The enjoyment of highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, economic and social condition. [1] Health is multifactorial, influenced by factors like genetics, lifestyle, environment, socioeconomic status (SES) and many others. [2] Health cannot be isolated from its social context and the last few decades have witnessed that social and economic factors have as much influence on health as the medical interventions. [2] Socioeconomic factors are important determinants of health and this is dramatically reflected in the comment of Naina, wife of Boris Yelstin, former Prime minister of Russia, who says, "we have astronauts flying in space ships but we don't have enough wheel chairs". [1] Over the last century, health has improved significantly. This improvement, however, has not been experienced equally across the population, being considerably greater among the better off. [3] High economic status alone cannot contribute to better health. [2] Although it is a major factor for improving the health, [4],[5],[6],[7] it can be a contributing factor for illness as well, like in the occurrence of coronary heart disease, diabetes and obesity. [2] Studies indicate that education to some extent compensates the effect of poverty on health. Kerala with its high literacy status has better health (low infant mortality rate) compared to other parts of India, in spite of having lesser per capita income than the national average

1. Check out ppt download link in description
Or
Download link : https://userupload.net/nzqpb47zspb8

2. Contents
Introduction
Social stratification
Social class/social status
Consequence of stratification
Socioeconomic status (SES)
Socioeconomic status scales
SES and oral health
- Theories of social inequality in oral health
- SES and attitudes
-SES and dental caries
- SES and periodontal disease

3. SES and oral cancer
SES and knowledge attitudes and practices
SES and utilization of dental services
Conclusions
References

4. Social Stratification/Social Inequality
“The process by which individuals and groups are
ranked in a more or less enduring hierarchy of status
is known as stratification”.
Ogburn and Nimkoff
“An arrangement of any social group or society into a
hierarchy of positions that are unequal with regard to
power, property, social evaluation and psychic
gratification”
Melvin Tumin

5. CLICK HERE TO DOWNLOAD
THIS PPT
https://userupload.net/nzqpb47zspb8

6. Stratification involves the distribution of unequal
rights and priviliges among the members of a society.
According to Gisbert “Social stratification is the
division of society into permanent groups or
categories linked with each other by the relationship
of superiority and subordination”.

7. Social class/ social status
Two types of social status
Ascribed Achieved
(e.g caste) (gained during the lifetime)
Open
A status group may be
Closed

8. Three basic and practical approaches have been
developed for the identification of social classes at
community and societal levels.
a) Reputational:-Implies a strategy in which
knowledgeable people are asked to rank individuals and
families in terms of their place in the community's
stratification structure
b) self-location:-Requires members of a community to
identify the social class to which they belong.
c) objective:- involves ranking individual/families
households on such standard criteria as income,
occupation and education.

9. Socioeconomic status:-
The position an individual or family occupies with
reference to prevailing average standards of cultural
and material possessions, income, and participation
in group activity of the community.
Scales for measuring socioeconomic status:-
UK:- based on occupation, area and neighbourhood
USA:- Income and years of education
Different countries – different methods

10. Health status is determined by the Socioeconomic
development, e.g, per capita GNP, education,
nutrition, employment, housing etc.
Those of major importance are:-
Economic status:- per capita GNP is the most widely
accepted measure of general economic performance.
it determines the purchasing power, standard of
living, quality of life, family size and patterns of
disease.
Education:-The worlds map of literacy closely
coincides with the maps of poverty, malnutrition,
illhealth, high infant Mortality.

11. Occupation:-being employed in productive work
promotes health. The unemployed usually show a
higher incidence of ill health and death.
Political systems:- The percentage of GNP spent on
health is a quantitative indicator of political
commitment,

12. Social scientists have used occupation widely as a means
of determining the level of social standing.
occupation is a major determinant of:-
a) Economic rewards
b) Extent of authority
c) extent of obligations
d)Degree of status
e) Values and lifestyles

13. Registrar General’s classification.
(England and Wales)
Social class Occupation
I Professional occupation
II Intermediate occupation
IIIN Non manual skilled occupation
IIIM Manual skilled occupation
IV Semiskilled occupation
V Unskilled

14. Limitations of occupational classification:-
Heterogeneous grouping
Occupational mobility
Women
Two occupations at the same time

15. CLICK HERE TO DOWNLOAD
THIS PPT
https://userupload.net/nzqpb47zspb8

16. Other measures of social differentiation
Education
Income
Purchasing power
Religion
Rural and Urban

17. In India – at individual or family level
Kuppuswamys scale-urban
Pareek’s –Rural family
Prasad classification
The National Statistics Socio-economic
Classifications (NS-SEC)

18. Kuppuswamys scale- 1976
He prepared a scale based on
Occupation
Education
Income
Disadvantage
- Does not take into account SES of family
- Family size is also not considered
- can be used only in urban areas

19. A) Education Score
1. Profession or Honours 7
2. Graduate or post graduate 6
3. Intermediate or post high school diploma 5
4. High school certificate 4
5. Middle school certificate 3
6. Primary school certificate 2
7. Illiterate 1
B) Occupation Score
1. Profession 10
2. Semi-Profession 6
3. Clerical, Shop-owner, Farmer 5
4. Skilled worker 4
5. Semi-skilled worker 3
6. Unskilled worker 2
7. Unemployed 1

20. (C) Family income per Score Modified Modified
month(in Rs)- original for 1998 for 2007
≥2000 12 ≥13500 ≥19575
1000-1999 10 6750-13499 9788-19574
750-999 6 5050-6749 7323- 9787
500-749 4 3375-5049 4894- 7322
300-499 3 2025-3374 2936-4893
101-299 2 676-2024 980-2935
≤ 100 1 ≤ 675 ≤ 979
Total Score Socioeconomic class
26-29 Upper (I)
16-25 Upper Middle (II)
11-15 Middle Lower middle (III)
5-10 Lower Upper lower (IV)
<5 Lower (V)

21. Prasad’s classification
Based on per capita income of family

22. Pareek’s scale - 1975
Rural family
Based upon nine items
1. Caste
2. Occupation of head of family
3. Education of head of family
4. Level of social participation of the head of the
family
5. Land holding
6. Housing

23. 7. Farm power (draught animals like bullock, prestige
animals like camel, elephant, horse and mechanical
power)
8. Material possessions
9. Family (type of family, family size and distinctive
features of family in respect of persons other than the head
of family).
Five SES categories
Upper, upper middle, lower middle, upper lower, lower

24. 1. Higher managerial and professional occupations
1.1 Employers and managers in larger organizations (e.g.
company directors, senior company managers, senior civil
servants, senior officers in police and armed forces.)
1.2 Higher professionals (e.g. doctors, lawyers, clergy, teachers
and social workers.)
2. Lower Managerial and professional occupations (e.g. nurses
and midwives, journalists, actors, musicians, prison officers,
lower ranks of police and armed forces.)
3. Intermediate occupations (e.g. clerks, secretaries, driving
instructors, telephone fitters.)
The National Statistics Socio-economic
Classifications (NS-SEC)

25. CLICK HERE TO DOWNLOAD
THIS PPT
https://userupload.net/nzqpb47zspb8

26. 4.Small Employers and own account workers (e.g.
publicans, farmers, taxi drivers, window cleaners,
painters and decorators.)
5. Lower supervisory, craft and related occupations
(e.g. printers, plumbers, television engineers, train
drivers, butchers.)
6. Semi-routine occupations (e.g. shop assistants,
hairdressers, bus drivers, cooks.)
7. Routine occupations (e.g. couriers, laborers, waiters
and refuse collectors.)
8. Who have never had paid work and the long term
unemployed

27. SOCIOECONOMIC STATUS AND ORAL HEALTH

28. Black Report - 1980
Theories of Social inequalities in oral health
Artefact
Natural or social selection
Cultural explanations
Material explanations

29. ARTEFACT
Inequalities in health are not real but artificial.
They are an effect produced in the attempt to
measure something (health, social class) which is
more complicated than the tools of measurement can
appreciate.

30. Natural and social selection
Explanations in term of selection accept that social
inequalities in health do indeed exist.
People in poor health would tend to move down the
occupational scale and concentrate in the lower social
classes, while in good health would tend to move up
into higher classes.
In other words the observed difference in health
reflect a process of social mobility.

31. Materialist explanations
Emphasizes the role of external environment, factors
which are beyond the individuals control( the
conditions in which people live and work, the
pressures on them to consume unhealthy products
etc).
Lower social groups are exposed to a more unhealthy
environment.
They do more dangerous work, have poor housing and
have fewer resources(e.g income) available to secure
the necessities for health and to use the available

32. Cultural or Behavioural explanations
It focuses on the behavioral and lifestyle choices
made by people from different socioeconomic
background.
Evidence suggests that poor health outcomes and
health damaging behaviours such as poor diet, lack of
exercise, smoking alcohol consumption are more
prevalent in lower socioeconomic groups(Watt R et al
1999) which appear to offer a direct mechanism to
explain the relationship between socioeconomic
status and healt.

33. Human behaviours are extremely complex, the
decision making process being influenced by
numerous social, economic and environmental
conditions.
Traditional behavioural explanations have been
challenged by an alternative model focusing on the
influence of culture in determining behavioral
choices.

34. Socioeconomic status and attitudes
The upper middle class:-
 The professional and business executive group ,
well educated, living in preferred areas.
 They value their teeth
 Interested in preventive dentistry
 Desire to have the teeth as long as possible
 Dentits- professional who not only repairs teeth but also makes
them attractive and useful.

35. The lower middle class:-
Owners of small business, minor executives, teachers, salesman
and white collar workers.
 At least a high school education
 Live in well maintained, clean, pleasant neighborhood
 They are most compulsive in their dental care attitudes
 Dentist- authority, who fixes teeth
 The necessity of being clean, good, conforming and socially
presentable makes for a high standard of dental care among
people in this group.

36. Upper Lower class :- “The group which needs to
become the objective of major educational efforts
regarding dental care and this is primarily because they
are most accessible to these attempts and offer the best
possibilities of behavioral and attitudinal changes”.
 skilled and semiskilled blue collar workers.
 They are people with limited education
 live in modest neighborhoods
 Resigned to whatever happens and feel that there is
little they can do to save off the inevitable
 No continuous relation with physician and dentists

37. The lower class:-
 Underprivileged or disadvantaged
 Unskilled labourers, live in slums
 limited education and exhibit no stable pattern of life
 They are the ones who reveal the most consistent neglect
of teeth.

38. Attitudes of underprivileged people towards oral health
Trithart in 1968
1) Castration complex:- reluctance to be at complete
mercy of the health practitioners
2)Contradiction of common sense
3)Coming in crowds
4)The last ditch effort
5)If it hurts you are a quack
6)Unclean or dirty feeling
7)The clinic was built there not here
8)Cold professional attitudes

39. 9) Difference in pain threshold
10) Complication of the unknown
11)The pills don’t work
12) Appointments are not important
13) Teeth lost anyhow
14)Traditions.

40. Disease of poverty or deprivation
Klein – lower SES – higher value for D & M,
lower values of F .
In today's world – higher SES groups –decline in
caries experience
Dental caries and socioeconomic status

41. 

42. In India
Dutta 1965
Schoolgoing children in Calcutta
Higher caries prevalence – lower social class
Dr.Sanjay Kalra 2007
Conducted a study on children from different SES
group.
Caries prevalence of was higher in low SES group.

43. Mahalkshmi Y et al., 2004
200 12yr Parkala schoolchildren
social class – prasad classification
No significant relation between dental caries and SES
Sogi GM et al., 2002
2007 children of 13 to 14 years age Davangere town
Dental caries experience and oral hygiene status of children -
strongly correlated to socio-economic status.
Shah N 2004
Delhi 1240 elderly 716 urban 524 rural
Dental caries – literacy level, location

44. Roberts CJ et al., 1993 (early childhood caries)
1263 1-4 yr African communities
Caries prevalence – lowest among social group I in all
groups
Sudha P et al 2005
Mangalore- 524 school children
prevalence of caries was higher in low SES group
(96.2%) compared to high SES group children(77.1%).

45. Periodontal disease and socioeconomic status
U.S. national survey

46. U.S. national survey

47. Jaani DQ et al., 2002
12-15 yr Jordan
Low – moderate SES – 347 public schools
High SES – 347 private schools
Public schools – bleeding on brushing & calculus
- mean plaque & gingival scores
- DMFT scores
As compared to Private schools
Susin et al., 2004
Urban, Brazilian population 1460
% teeth – recession – significantly higher in lower
SES

48. Jagadeesan M et al., 2000
Rural women Pondicherry
illiteracy, occupation – significant risk factors
Shah N., 2004
South Delhi 716 urban 524 rural 60+ age
SES – Rup Nagpal’s scale
Literacy level
No correlation between SES and literacy level and
periodontal health

49. Tooth loss
Gilbert GH et al., 2003
Social determinants of tooth loss > 45 years
African –Americans & lower SES – strong determinants
of tooth loss
Sanders AE et al., 2004
3678 adults 18-91yrs Australia
Low household income, blue-collar occupation & high
residential area disadvantage - + pathological tooth loss

50. US - National survey

51. Warnakulasuriya S 2009.
Oral cancer risk is significantly associated with low SES and
related to lifestyle risk factors.
Conway DI et al 2008 (systematic review and metaanalysis)
Compared individuals who were in high SES strata, the
pooled ORs for the risk of developing oral cancer were 1.85
(95%CI 1.60, 2.15; n = 37 studies) for those with low
educational attainment; 1.84 (1.47, 2.31; n = 14) for those with
low occupational social class; and 2.41 (1.59, 3.65; n = 5) for
those with low income.
Oral cancer and socioeconomic status

52. Knowledge, Attitude & Practices
Increased risk of unhealthy food habits in children of
less educated parents.
de Vries et al., 1990
Lack of further education, being Asian, & living in
deprived area - dental knowledge & +ve dental
attitudes among parents
Williams NJ et al., 2002

53. Oral health practices - DCI
Fingercleaning – rural
Tooth Brush – urban
Tobacco smoking – higher in rural areas
Knowledge – low – more in rural areas

54. Utilization of dental services

55. Taani DQ et al., 2002
conducted a study in Jordan on 1021 schoolchlidren(14 yrs)
Public schools (lower-middle SES)
Private school (higher SES)
Private Public
Dental attendence 31.4% 15%
Dental attendence
in pain
67.4% 82.6%

56. Srivastava RP et al., 1994
130 patients Jhansi
Social
class
I,II,III
NM
Social
class
IIIM
Social
class
IV/V
other
Regular
attende
r
15 2 9 13
Irregula
r
attende
r
18 12 47 14
Literacy level - barrier to preventive care and treatment
Rudd R et al., 2005

57. Conclusions
Why SES?
Clinician
- attitude to diseases
- oral health education
- treatment planning

58. Public health dentist
- Attitude to diseases
- Health inequalities research
- Service planning
- Policy formulation
- Organization of dental care
- Designing effective programs
- Evaluation
- Oral health promotion – SES – health inequalities

59. REFERENCES
Park. Social sciences and health. In: Park. Social & preventive
medicine. 2005. 18th
ed.506-518.
Petersen PK. Society and oral health. In. Pine CM. Community oral
health. 1997.ed. Mumbai. Km Varghese company. 20-37.
Kulkarni AP. Textbook of community Medicine. 2002. 2nd
ed.
Mumbai. Vora medical publication. 28-35.
Beal JF. Social factors and preventive dentistry. In: Murray JJ.
Prevention of dental disease. 1983. 2nd
ed. New York. Oxford
university press.313-342.

60. Burt. Dentistry, dental practice and community. 2005. 6th
ed.
Dunning JM. Social sciences. In: Dunning JM. Principles of dental
public health. 4th
ed. 1986. England. Harvard University press. 185-
207.
Peter S. social sciences in dentistry. In: Peter S. Essentials of
preventive and community dentistry. ed. 2001. New Delhi. Arya
Publishing house. 733-741.
National fluoride mapping by DCI 2002-2003.
Thomson WM et al. Socioeconomic inequalities in oral health in
childhood and adulthood in a birth cohort. CDOE 2004; 32: 345-
53.

61. Newton JT. The social determinants of oral health: new approaches
to conceptualizing and researching complex causal networks. CDOE
2005; 33: 25-34.
Mishra D & Singh HP. Kuppuswamy’s socioeconomic status scalr. –
a revision. Ind J Pediatrics 2003; 70: 273-4.
Gilbert GH et al. Social determinants of tooth loss. Health Serv Res.
2003 Dec;38(6 Pt 2):1843-62.
Sanders AE et al. Social inequality in perceived oral health among
adults in Australia. Aust N Z J Public Health. 2004 Apr;28(2):159-
66.
Mahalakshmi Y et al. Estimation and comparison of significant
caries index and the pattern of sugar consumption among 12 yr old
school going children of two different socio economic strata. IJDR
2004; 15(1): 20-23.

62. Vargas CM et al. Oral health status of rural adults in the United
States.J Am Dent Assoc. 2002 Dec;133(12):1672-81.
Marcus PA et al. Complete edentulism and denture use for elders
in New England. J Prosthet Dent. 1996 Sep;76(3):260-6.
Shah N. Impact of socio demographic variables, oral hygiene
practices and oral habits on periodontal health status of Indian
elderly: a community based study. IJDR 2003; 14(4): 289-297.

63. Locker D. Deprivation and oral health: a review. CDOE 2000; 28:
161-9.
Roberts GJ. Patterns of breast and bottle feeding and their association
with dental caries in 1- to 4-year-old South African children. 1. Dental
caries prevalence and experience. Community Dent Health. 1993
Dec;10(4):405-13.
Rahamtulla M. Relationship between water fluoride level and
socioeconomic class in 15 year old Indian school children. IJDR 1993;
14: 17-20.
Klinge B et al. A socioeconomic perspective on periodontal disease.- a
systematic review. J clin periodontol 2005; 32(s6): 314-25.

64. Nicolau B. A life course approach to assessing causes of dental
caries experience: the relationship between biological, behavioural,
socio-economic and psychological conditions and caries in
adolescents. Caries Res. 2003 Sep-Oct;37(5):319-26.
Hashibe M . Socioeconomic status, lifestyle factors and oral
premalignant lesions.Oral Oncol. 2003 Oct;39(7):664-71.
Greenberg RS. The relation of socioeconomic status to oral and
pharyngeal cancer.Epidemiology. 1991 May;2(3):194-200.

65. Sociological schools of thoughts
Sociology provides several perspective for looking at
human or group behavior:
a)Functionalism or consensus
b)Conflict theory
c)Interactionism

66. B.G.Prasad’s classification
Social class Percapita monthly income limits
1961 1968 1970
I 100 and above 270 and above 300 and above
II 50-99 130-269 150-299
III 30-49 80-129 70-149
IV 15-29 40-79 30-69
V Below 15 Below 40 Below 30

67. Consequences of Stratification
Three umbrella like dimensions:-
1) Life chances
2)Lifestyles
3)Personality

68. Psychosocial perspective
Health inequalities result from the differences in the
experience of psychological stress between
socioeconomic groups.
Lower socioeconomic backgrounds are hypothesized
to experience higher levels of psychosocial stress
resulting from a higher number of negative life
events, having lower levels of social support, less
control at work, Less job security and living in
communities with lower levels of trust and higher
levels of crime, than from higher socioeconomic
status.

69. Stress could influence health by two mechanisms:-
Direct:- by releasing certain mediators which have a
negative effect on the body.
Indirect:- people with higher levels of stress are more
likely to make behavioral or lifestyle choices which
are damaging to health.

70. Life course perspective:-
Health status at any given age is a result not only of
current conditions but also of the embodiment of
prior living conditions from conception onwards.
Health inequalities therefore result from the
interaction of materialist, behavioral and psychosocial
factors over time.
Two models:- Accumulation model
Critical periods or latent effects model

71. Accumulation model:- exposure to advantage or
disadvantage at different stages of life course has a
cumulative effect and this increases or decreases the risk of
developing chronic disease.
Critical period model:- Chronic diseases such as heart
diseases have their origins during critical periods of
development.
Thompson et al 2004 demonstrated that adult oral health
can be predicted by childhood socioeconomic disadvantage
and also oral health in childhood.
Nicolau et al demonstrated that socioeconomic and
biological risk factors in early life are significantly related to
dental caries experience at 13 years of age.

72. WHO classification - 2004
Occupation
0 – non-skilled worker (peon, labourer)
1- skilled worker (carpenter, masion)
2- Professional
3- Business
4- House-wife
5- school-going child
6- non school going child
7- farmers/local occupation
8- non-employed
9- no available information

73. Dental caries and socioeconomic status
U R Rehmann et al 2008:- dental caries in 11-14 year
children using DMFT index.
Caries was significantly inversely related to
socioeconomic status

74. Tyagi et al 2008:- preschool children in davangere,
found that nursing caries was more prevalent in low
socioeconomic groups.
Grytten et al. ,Chosack et al. ,Grindefjord et al. and
Louie et al.
 Mahalkshmi Y et al., 2004:- no correlation between
socioeconomic status and dental caries.

75. Thank you