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Exploring the Impact of Complex Socioeconomic, Psychometric And NATIONAL AND KAPODISTRIAN UNIVERSITY OF ATHENS SCHOOL OF HEALTH SCIENCES DEPARTMENT OF DENTISTRY DOCTORAL DISSERTATION IN DENTAL SCIENCE Exploring the impact of complex socioeconomic, psychometric and behavioral factors and the social gradient concerning clinical and subjective measures of oral health, in Greek older adults Popie Damaskinos ATHENS 2020 THREE-MEMBER ADVISORY COMMITTEE Supervisor: Associate Professor Charitini Koletsi-Kounari Members: Associate Professor Eleni Mamai-Homata Associate Professor William Papaioannou SEVEN-MEMBER EXAMINATION COMMITTEE Supervisor: Associate Professor Charitini Koletsi-Kounari Members: Associate Professor Eleni Mamai-Homata Associate Professor William Papaioannou Professor Argy Polychronopolou Associate Professor Sotiria Gizani Professor Anastassia Kossioni Assistant Professor Anastasia Mitsea The approval of the Doctoral Dissertation (PhD) by the Department of Dentistry of NKUA does not indicate acceptance of the author’s opinion Organization of NKUA, Chapter 202, paragraph 2, Law 5343/1932. ΕΘΝΙΚΟΝ ΚΑΙ ΚΑΠΟΔΙΣΤΡΙΑΚΟΝ ΠΑΝΕΠΙΣΤΗΜΙΟΝ ΑΘΗΝΩΝ ΣΧΟΛΗ ΕΠΙΣΤΗΜΩΝ ΥΓΕΙΑΣ ΤΜΗΜΑ ΟΔΟΝΤΙΑΤΡΙΚΗΣ ΔΙΔΑΚΤΟΡΙΚΗ ΔΙΑΤΡΙΒΗ ΣΤΗΝ ΟΔΟΝΤΙΑΤΡΙΚΗ ΕΠΙΣΤΗΜΗ Διερεύνηση σύνθετων κοινωνικοοικονομικών, ψυχομετρικών και συμπεριφορικών παραγόντων και διαβαθμισμένων ανισοτήτων σε κλινικούς και υποκειμενικούς δείκτες στοματικής υγείας ατόμων τρίτης ηλικίας, στην Ελλάδα Πόπη Δαμασκηνού ΑΘΗΝΑ 2020 ΤΡΙΜΕΛΗΣ ΣΥΜΒΟΥΛΕΥΤΙΚΗ ΕΠΙΤΡΟΠΗ Επιβλέπουσα: Αν. Καθηγήτρια κ. Χαριτίνη Κωλέτση-Κουνάρη Μέλη: Αν.Καθηγήτρια Ελένη Μαμάη - Χωματά Αν.Καθηγητής Βασίλειος Παπαϊωάννου ΕΠΤΑΜΕΛΗΣ ΕΞΕΤΑΣΤΙΚΗ ΕΠΙΤΡΟΠΗ Επιβλέπουσα: Αν.Καθηγήτρια κ. Χαριτίνη Κωλέτση-Κουνάρη Μέλη: Αν.Καθηγήτρια Ελένη Μαμάη-Χωματά Αν.Καθηγητής Βασίλειος Παπαϊωάννου Κα θηγήτρια Αργυρώ Πολυχρονοπούλου Αν.Καθηγήτρια Σωτηρία Γκιζάνη Καθηγήτρια Αναστασία Κοσιώνη Επίκουρη Καθηγήτρια Αναστασία Μητσέα Η έγκριση της Διδακτορικής Διατριβής από το Τμήμα Οδοντιατρικής του Ε.Κ.Π.Α, δεν υποδηλώνει ότι αποδέχεται τη γνώμη του συγγραφέα. Οργανισμός Πανεπιστημίου Αθηνών, Άρθρο 202, παρ. 2, Ν. 5343/1932. Αφιερώνεται στους γονείς μου για το ζην, στους Δασκάλους μου για το ευ ζην. “I am indebted to my father for living, but to my teacher for living well” Alexander the Great Table of Contents Abbreviations .................................................................................. iii Summary .......................................................................................... v Acknowledgments ........................................................................... ix List of Tables ..................................................................................... x List of Figures ................................................................................. xiv List of publications and conference presentations ........................ xv PART 1 Chapter 1 Introduction ..................................................................................... 1 1.1 The importance of an ageing population ................................... 4 1.2 Demographic changes in Greece ............................................... 5 Chapter 2 Literature Review ............................................................................ 7 2.1 Social inequalities ....................................................................... 7 2.2 Social Inequalities and the social gradient in health ................. 9 2.3 Social determinants of health and oral health ........................ 16 2.4 Pathways and mechanisms of the social gradient ................... 23 2.5 Social networks ........................................................................ 37 2.6 Cognitive ability ........................................................................ 42 2.7 Subjective measures of oral health and Oral Health Quality of Life .......................................................................... 57 2.8 Theoretical model .................................................................... 67 2.9 Study rationale ......................................................................... 70 PART 2 Aim …… .................................................................................... 71 Objectives ....................................................................................... 71 Hypotheses ..................................................................................... 72 i Chapter 3 3.1 Methods and material .............................................................. 73 3.2 Sampling frame and sample size .............................................. 74 3.3 Municipalities and recruitment................................................ 76 3.4 Study Population-Inclusion and exclusion criteria ................... 76 3.5 Interviews and questionnaires ................................................. 77 3.6 Questionnaire coverage and Measures ................................... 79 3.7 Clinical and subjective Measures ............................................. 85 3.8 Ethics ........................................................................................ 86 3.9 Data analysis............................................................................. 87 Chapter 4 Results ............................................................................................ 89 4.1 Results for objective 1 .............................................................. 92 4.2 Results for objective 2 ............................................................ 105 4.3 Results for objective 3 ............................................................ 114 4.4 Results for objective 4 ............................................................ 123 Chapter 5 Discussion ..................................................................................... 153 Conclusions .................................................................................. 167 Suggestions for future research ................................................... 169 References ................................................................................... 171 Appendices Appendix 1 ................................................................................... 217 Appendix 2 ................................................................................... 224 Appendix 3 ................................................................................... 231 Appendix 4 ................................................................................... 234 Abstract in Greek.......................................................................... 279 ii Abbreviations ADL Activities of Daily Life DMFT Decayed, Missing and Filled Teeth ELSA English Longitudinal Study of Ageing ISCED International Standard for Education Classification MMSE Mini Mental State Examination NDNS National Dental and Nutrition Study NHNES National Health and Nutrition Examination Survey OECD Organization for Economic Corporation and OHIP OralDevelopment Health Impa ct Profile OIDP Oral Impacts on Daily Performance OHRQL Oral Health Related Quality of Life OR Odds Ratio SHARE Survey of Health, Ageing and Retirement in Europe SEP Socioeconomic Position SES Socioeconomic Status SSS Subjective Social Status SWL Satisfaction with Life WHO World Health Organization iii iv Summary It is very well-established that there are social inequalities affecting health and mortality. Longevity for those at the lower end of the social status ladder is considerably less attainable than those higher up the ladder; the higher one climbs up the social ladder, the better one’s health. In spite of the well-documented differences in morbidity and mortality across the social spectrum, the amount and level of the gradient varies depending on the stage of life, gender, country, indicators of health and indicators of social inequality. These social class inequalities exist for almost all chronic diseases in industrial countries; similarly, these inequalities are also apparent in oral health. However, there is relatively little research available regarding these issues, for both clinical and subjective measures, in the ageing population of industrialized countries. Interest in ageing populations and social inequalities has increased in recent years. Ageing populations and chronic diseases are both concerns for all industrial countries. This study is a cross-sectional epidemiological study in Athens and the Greater area of Athens. The principal aim of the study is to explore the impact of complex socioeconomic, psychometric and behavioural factors and the social gradient in clinical measures, tooth loss, sum of Decayed Missing Filled Teeth (DMFT), Oral Health Index Simplified (OHIS), as well as subjective measures such as self-reported oral and self-reported general health in a Greek population aged 65 years old and over. More specifically, the purpose is to explore and investigate the association between perceived, subjective and clinical measures of oral health and wellbeing for these older adults, and the extent to which these relationships vary according to socioeconomic indicators (education, occupation, income and subjective social status). Psychosocial factors such as acute and chronic stress, stressful experiences at work, loneliness, social organization, social networks and social support affect health; thus, the study assess whether the social inequalities and the gradient in oral health are influenced by psychometric factors such as: social networks, v cognitive ability, life satisfaction, and loneliness. Inequalities in health are unfair differences
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