Self-perception of oral health,gender and employment among Brazilian population

Abstract

BACKGROUND:

Self-perception of oral health is a recognized indicator, based on a single question. Association among oral health and socioeconomic status has been well established, however in Brazil, no results were found on the relation with type of insertion in labor market.

OBJECTIVE:

The aim of this study was to describe the prevalence of negative self-perception of oral health and associated factors, according to gender among Brazilian workers population, in 2019.

METHODS:

The National Health Survey, nationwide household-based survey, carried out in 2019, was used as source of data. Absolute and relative frequencies were calculated to understand the distribution of variables of interest and characterize the sample (n = 54,343). Binary logistic regression was used in the analyses. Odds ratio (OR) was estimated using a 95% confidence interval in bivariate and multivariate analyses.

RESULTS:

The prevalence of negative self-perception of oral health was 29.3%; in that, 31.0% among men and 27.2% among women. Compared to formal employees, the chance of negative self-perception of oral health among the informal workers was almost 20% higher among men and 13% among women after adjusting for all confounding factors. Unemployed women were 33% more likely to have negative self-perception of oral health.

CONCLUSIONS:

Self-reported unemployment increased the chance of a negative self-perception of oral health among women; however, the same effect was not observed among men. Why is there a difference? The association between informal work and negative SEOH is relevant in the Brazilian context of work deregulation and growth in the number of people without access to formal employment. The results suggested addressing employment conditions in adult oral health promotion actions, with emphasis on gender differences.

Keywords

Oral health gender employment public health dentistry dental health surveys health inequities

1 Introduction

Self-perception of oral health is a recognized indicator of general health, wellbeing, and quality of life [1, 2]. Based on a simple question, the respondent defines their oral health status in a five-point Likert scale (1. very good; 2. good; 3. acceptable; 4. poor; 5. very poor) [3]. The result is associated with the prevalence of dental caries, tooth loss, and other oral diseases. Using this resource, it is possible to find differences between population subgroups and identify the need for dental services, according to the geographic area [4]. Evidence can be found regarding the relation between income [5, 6], education [4], profession [7, 8], and the self- efficacy scale for oral health behavior. Occupation is considered, together with education and income, one of the pillars of socioeconomic factors. Despite having already been addressed in research in the field of dentistry, gaps in knowledge still persist, even though the influence of working conditions on health results is a known fact [8, 9].

Formal work, informal work, and unemployment are distinct types of insertion in the labor market, and are related to the likelihood of exposure to stressful and polluted environments [10], unbalanced diet [11], and behaviors harmful to oral health [12], among other factors that interfere in self-perception of general and oral health. A prevalence of negative self-perception of oral health was identified among unemployed as compared to employed individuals [13].

Another important gap in oral health studies concerns the influence of gender on the way individuals perceive their oral health status when exposed to different types of inclusion in the workforce and employment conditions. Gender inequality is present in the labor market. Historically, household tasks, care of children, elderly and ill relatives have been tasks attributed to women; i.e., work associated to the reproduction of life. Through the logic of gender division of labor, the norm historically constructed for men is to be the family breadwinner, dedicating more hours per week to the formal labor market, holding positions in the primary and secondary economy sectors; moreover, males are paid better salaries and have access to more labor rights and health care. Paid female workers, by contrast, are associated to “typically feminine” jobs, such as those in the services sector, performing tasks like teaching, caretaking, feeding, cleaning, etc. Those positions often provide less social prestige and pay lower salaries, require atypical shifts and part-time contracts, with no welfare coverage [14].

To examine the hypothesis of differences oral health results for the genders, male and female, and admitting the existence of gender occupational segregation, the present study aimed to describe the prevalence of negative self-perception of oral health and associated factors, according to gender among Brazilian workers population, in 2019.

2 Material and methods

2.1 Study design

This is a cross-sectional study carried out with secondary data, used data from the National Health Survey (PNS, acronym in Portuguese) 2019 (https://www.ibge.gov.br), a nationwide cross-sectional study conducted by the Brazilian Ministry of Health in partnership with the Brazilian Institute of Geography and Statistics (IBGE). The population surveyed corresponds to residents of permanent private households in Brazil, except those located in special census sectors (composed of subnormal agglomerations; barracks, military bases, etc.; accommodation, camps, etc.; vessels, boats, ships, etc.; indigenous villages; penitentiaries, penal colonies, prisons, jails, etc.; nursing homes, orphanages, convents, hospitals, etc.; and rural settlements). The PNS sampling plan was by conglomerates, in three stages of selection, with stratification of primary sampling units (UPA), represented by census sectors or sets of sectors. In the first stage, the selection of UPA was carried out by simple random sampling. In the second stage, a fixed number of permanent private households were randomly selected from each UPA selected in the first stage. In the third stage, within each household in the sample, one resident was selected with equiprobability, from a list of eligible residents constructed at the time of the interview, to respond to the individual interview [15].

The PNS was approved by the National Commission on Research Ethics (CONEP, acronym in Portuguese) in August 2019, under decision number 3,529,376, complying with what set forth in Decree 196/96, ratified by the National Health Council, in an attempt to facilitate participants’ decisions to enroll in studies, in addition to granting anonymity and the possibility of withdrawal at any moment of the study [15].

2.2 Eligibility criteria

Respondents of the PNS 2019, aged 18 years or older, included in the Economically Active Population; in other words, both employed and unemployed individuals were considered eligible for participation. After the employers had been excluded (1,868 individuals), a sample of 54,343 individuals was obtained, all of whom answered the key questions to explore the guiding hypothesis of this study.

2.3 Variables

The outcome variable “self-perception of oral health” was prepared according to answers to the question from the oral health module: U5 “In general, how do you evaluate your oral health (teeth and gums)?”: 1. very good; 2. good; 3. acceptable; 4. poor; 5. very poor. The answers were analyzed by means of constructing the dichotomous variable: 1. positive self-perception of oral health (very good and good); and 2. negative self-perception of oral health (acceptable, poor, and very poor) [3 , 7].

The covariable “insertion in the labor market” received the primary analytical focus, and it was classified as three categories: formal employment, informal employment, and unemployment. Participants who answered question E11 – “How many jobs did the respondent have in the week of July 21 to 27, 2019 (reference week)?” were considered to be employed, whereas participants were considered to be unemployed if they responded positively to questions E22 – “In the period between June 28 and July 27, 2019 (30-day reference period), did you try to find work, be it a job or your own business?” and E26 – “If you had found a job, could you have started in the week of July 21 to 27, 2019 (reference week)?”, and if they reported having made an effort to find work in question E23a – “In the period between June 28 and July 27, 2019 (30- day reference period), what was the main attitude you took to get a job?.”

The category “employed” was classified as formal workers (1. registered domestic worker; 2. military service; 3. employed by the private sector and registered; and 4. employed by the public sector, and registered) and informal workers (1. unregistered domestic worker; 2. employed by the private sector but unregistered; 3, employed by the public sector but unregistered; 4. self-employed; 5. unpaid worker who helps family members or relatives).

The covariables able to influence the association among type of insertion in the labor market and the self-perception of oral health were as follows: age (18–34, 35–44, 45–59, and ≥60 years); self-declared race/color (white and non-white); marital status (lives with a spouse or without a spouse); geographic region of the country (South, Southeast, Midwest, North, and Northeast); place of residency (urban or rural); and education level (uneducated, elementary, high school, and college).

Per capita family income (minimum wage salaries (SM, acronym in Portuguese) was calculated based on question referent per capita household income. The calculation was done by dividing the value of the per capita household income by the value of a minimum wage salary in 2019 (R$998,00). The analysis was based on four categories: <1 SM;≥1 and ≤3 SM;>3 and ≤6 SM; and > 6 SM.

In relation to oral health status, five variables were considered: tooth loss (<13 teeth and ≥13 teeth); limitation of ability to eat: absent (no limitation) and present (mild, moderate, and intense); tooth brushing (at least twice a day and more than twice a day); dental appointment in the last 12 months (yes and no); self-evaluation of general health (positive or negative).

2.4 Data analysis

The analyses were conducted using the Stata statistics software, version 16.0. Weighing related to the sample design of the study was taken into consideration. First, descriptive analyses of data were conducted by calculating the relative and absolute frequencies, aiming to understand the distribution of the variables of interest and to characterize the sample. The distribution of variables was stratified according to gender. The comparison between men and women was analyzed by the chi-squared test, considering a significance level of 5%. The binary logistic regression model was used to examine possible associations between negative self-perception of oral health and type of insertion in the labor market.

The strategy to adjust the model according to possible confounding factors was to organize the variables into two blocks: (1) demographic and socioeconomic conditions and (2) health and behavior. The odds ratio (OR) values were estimated with a 95% confidence interval (95% CI) in bivariate and multivariate analyses. The final model maintained the significant variables at a significance level of 5%. Possible interactions were tested after adjusting the model. The quality of this adjustment was evaluated by the Hosmer & Lemeshow test.

3 Results

The study sample included 54,343 individuals, 53.9% men and 46.1% women. Table 1 presents the distribution of the sample (percentage with sample weight) according to the variables of interest stratified by gender. The prevalence of negative self-perception of oral health was 29.3%, and it was higher among men (31%) than women (27.2%). Gender differences were observed in all results, except for per capita household income (p > 0.05).

Table 1
Characterization of the study population (n = 54,343) according to the variables of exposure, outcome, and covariables by gender, PNS, 2019, Brazil

Variables Percentage*

Total sample Male Female p-value

SEOH

Positive 70.7 69.0 72.8 < 0.001

Negative 29.3 31.0 27.2

Insertion in the labor market

Formal Employment 43.4 44.7 41.9 < 0.001

Informal Employment 48.4 49.0 47.6

Unemployment 8.2 6.3 10.5

Socioeconomic and demographic conditions

Age (years)

18–34 38.4 38.6 38.2 0.002

35–44 25.5 24.4 26.8

45–59 28.1 28.3 27.8

≥60 8.1 8.7 7.2

Race/Color

White 42.3 40.9 44.0 < 0.001

Non-white 57.7 59.1 56.0

Level of education

Higher education 18.7 14.9 23.2 < 0.001

High School 40.4 38.2 42.8

Elementary 15.1 16.9 12.9

No formal education 25.9 30.0 21.0

Per capita household income in SM**

>6 3.6 3.4 3.7 0.726

>3 and ≤6 7.9 7.9 8.0

≥1 and ≤3 41.4 41.4 41.5

<1 47.1 47.3 46.8

Geographic region

South 14.8 14.8 14.9 < 0.001

Southeast 44.7 43.4 46.2

Midwest 8.1 8.1 8.0

North 7.9 8.4 7.2

Northeast 24.6 25.4 23.7

Area of residency

Urban 87.7 84.8 91.1 < 0.001

Rural 12.3 15.2 8.9

Lives with spouse

Yes 63.2 69.1 56.4 < 0.001

No 36.8 30.9 43.6

Results of health and behavior

Loss of ≥ 13 teeth

No 93.1 94.0 92.2 < 0.001

Yes 6.9 6.0 7.8

Limited capacity to eat

Absent 90.9 92.1 90.0 < 0.001

Present 9.1 7.9 10.0

Tooth brushing < 0.001

≥2 times a day 96.3 94.5 98.4

<2 times a day 3.7 5.5 1.6

Dental appointment in the last 12 months

Yes 53.1 47.0 60.2 < 0.001

No 46.9 53.0 39.8

Self-rated health

Positive 73.2 76.0 69.9 < 0.001

Negative 26.8 24.0 30.1

Variables		Percentage*
SEOH
Positive	70.7	69.0	72.8	< 0.001
Negative	29.3	31.0	27.2
Insertion in the labor market
Formal Employment	43.4	44.7	41.9	< 0.001
Informal Employment	48.4	49.0	47.6
Unemployment	8.2	6.3	10.5
Socioeconomic and demographic conditions
Age (years)
18–34	38.4	38.6	38.2	0.002
35–44	25.5	24.4	26.8
45–59	28.1	28.3	27.8
≥60	8.1	8.7	7.2
Race/Color
White	42.3	40.9	44.0	< 0.001
Non-white	57.7	59.1	56.0
Level of education
Higher education	18.7	14.9	23.2	< 0.001
High School	40.4	38.2	42.8
Elementary	15.1	16.9	12.9
No formal education	25.9	30.0	21.0
Per capita household income in SM**
>6	3.6	3.4	3.7	0.726
>3 and ≤6	7.9	7.9	8.0
≥1 and ≤3	41.4	41.4	41.5
<1	47.1	47.3	46.8
Geographic region
South	14.8	14.8	14.9	< 0.001
Southeast	44.7	43.4	46.2
Midwest	8.1	8.1	8.0
North	7.9	8.4	7.2
Northeast	24.6	25.4	23.7
Area of residency
Urban	87.7	84.8	91.1	< 0.001
Rural	12.3	15.2	8.9
Lives with spouse
Yes	63.2	69.1	56.4	< 0.001
No	36.8	30.9	43.6
Results of health and behavior
Loss of ≥ 13 teeth
No	93.1	94.0	92.2	< 0.001
Yes	6.9	6.0	7.8
Limited capacity to eat
Absent	90.9	92.1	90.0	< 0.001
Present	9.1	7.9	10.0
Tooth brushing				< 0.001
≥2 times a day	96.3	94.5	98.4
<2 times a day	3.7	5.5	1.6
Dental appointment in the last 12 months
Yes	53.1	47.0	60.2	< 0.001
No	46.9	53.0	39.8
Self-rated health
Positive	73.2	76.0	69.9	< 0.001
Negative	26.8	24.0	30.1

p-value: χ² test for comparison between sexes. *Considering the sample weighting. **Value of the minimum salary (SM) in 2019: BRL 998.00. Source: Instituto Brasileiro de Geografia e Estatística. PNS 2019.

Among men, the chance of a negative self-perception of oral health was 1.62- and 1.60-fold higher, respectively, in the groups reporting informal work and unemployment, respectively, as compared to formal workers. Among women, the chances of negative self-perception of oral health were 1.68- and 2.01-fold higher for those who reported informal work and unemployment, respectively, in comparison to formal workers (Table 2).

Table 2

Factors associated with the negative self-rated oral health (SEOH) (n = 54,343) according to gender, PNS, 2019, Brazil

Variables	Male		Female
	% SEOH Negative*	OR [95% IC]	% SEOH Negative*	OR [95% IC]
Insertion in the labor market
Formal Employment	18.9	1.00	24.0	1.00
Informal Employment	28.7	1.62[1.48–1.78]	34.7	1.68[1.52–1.87]
Unemployment	24.3	1.60[1.32–1.95]	33.5	2.01[1.69–2.39]
Socioeconomic and demographic conditions
Age (years)
18–34	26.9	1.00	23.2	1.00
35–44	30.2	1.18[1.04–1.33]	27.8	1.28[1.13–1.45]
45–59	36.0	1.53[1.36–1.73]	31.5	1.52[1.34–1.73]
≥60	35.7	1.51[1.32–1.74]	29.8	1.41[1.17–1.70]
Race/Color
White	26.6	1.00	21.3	1.00
Non-white	34.1	1.43[1.29–1.59]	31.8	1.72[1.53–1.93]
Level of education
Higher education	17.5	1.00	15.4	1.00
High School	25.9	1.65[1.43–1.91]	25.3	1.87[1.61–2.16]
Elementary	36.0	2.66[2.26–3.13]	35.1	2.98[2.52–3.53]
No formal education	41.5	3.35[2.89–3.90]	39.3	3.57[3.07–4.15]
Per capital household income in SM**
>6	13.7	1.00	7.8	1.00
>3 and ≤6	18.7	1.45[1.08–1.95]	12.4	1.66[1.11–2.49]
≥1 and ≤3	27.3	2.38[1.86–3.04]	22.5	3.43[2.39–4.90]
<1	37.6	3.81[3.00–4.83]	35.4	6.46[4.53–9.21]
Geographic region
South	26.1	1.00	21.9	1.00
Southeast	28.5	1.13[0.98–1.30]	24.2	1.14[0.98–1.33]
Midwest	29.0	1.15[1.00–1.33]	27.7	1.37[1.15–1.63]
North	32.9	1.39[1.22–1.58]	28.0	1.39[1.19–1.62]
Northeast	38.2	1.75[1.55–1.98]	36.0	2.01[1.74–2.31]
Area of residency
Urban	29.9	1.00	26.4	1.00
Rural	37.5	1.41[1.29–1.55]	35.4	1.53[1.33–1.76]
Lives with spouse
Yes	32.1	1.00	28.0	1.00
No	28.6	0.85[0.77–0.94]	26.1	0.91[0.82–1.00]
Results of health and behavior
Loss of ≥ 13 teeth
No	30.8	1.00	26.4	1.00
Yes	34.7	1.19[1.04–1.37]	36.1	1.57[1.31–1.89]
Limited capacity to eat
Absent	27.5	1.00	22.7	1.00
Present	72.4	6.94[5.98–8.06]	66.1	6.64[5.68–7.77]
Tooth brushing
≥2 times a day	29.7	1.00	26.7	1.00
<2 times a day	51.8	2.55[2.14–3.02]	49.6	2.70[1.96–3.73]
Dental appointment in the last 12 months
Yes	25.3	1.00	23.0	1.00
No	36.2	2.80[2.43–3.23]	33.5	1.69[1.52–1.87]
Self-rated health
Positive	24.4	1.00	19.4	1.00
Negative	52.1	3.37[3.06–3.72]	45.3	3.45[3.14–3.78]

*Considering the sample weighting. **Value of the minimum salary (SM) in 2019: BRL 998.00. Source: Instituto Brasileiro de Geografia e Estatística. PNS 2019.

The multivariate analysis after adjustment for demographic and socioeconomic variables among men indicated less association for formal workers (OR = 1.29; 95% CI = 1.16–1.42) and for unemployed (OR = 1.30; 95% CI = 1.05–1.60), maintaining the statistical significance. When adjusted by the health variables and behavior, less association with the main exposure was also observed, with no significant difference for the group of unemployed when compared to those with formal employment (OR = 1.13; 95% CI = 0.90–1.41). For the group of informal workers, the chance of a negative self-perception of oral health was nearly 20% higher when compared to the formal workers, after adjustment for all confounding factors (OR = 1.19; 95% CI = 1.07–1.33) (Table 3).

Table 3

Multivariate analysis evaluating the socioeconomic, demographics, and health factors in the Negative SEOH among adult male Brazilians, according to data from the PNS, Brazil, 2019

Variables	OR (95% CI) Not	OR (95% CI) Model	OR(95% CI) Model
	adjusted	adjusted by	adjusted by socioeconomic,
		socioeconomic and	demographic, and health
		demographic variables	variables
Insertion in the labor market
Formal Employment	1.00	1.00	1.00
Informal Employment	1.62[1.48–1.78]	1.29[1.16–1.42]	1.19[1.07–1.33]
Unemployment	1.60[1.32–1.95]	1.30[1.05–1.60]	1.13[0.90–1.41]
Socioeconomic and demographic conditions
Age (years)
18-34		1.00	1.00
35-44		1.19[1.06–1.35]	1.11[0.98–1.26]
45-59		1.52[1.35–1.72]	1.23[1.08–1.40]
≥60		1.50[1.28–1.75]	1.15[0.95–1.40]
Race/Color
White		1.00	1.00
Non-white		1.16[1.03–1.30]	1.10[0.97–1.24]
Level of education
Higher education		1.00	1.00
High School		1.32[1.12–1.56]	1.21[1.02–1.44]
Elemetary		1.91[1.59–2.31]	1.59[1.31–1.93]
No formal education		1.97[1.64–2.37]	1.45[1.19–1.76]
Per capita household income in SM**
>6		1.00	1.00
>3 and ≤6		1.29[0.96–1.73]	1.38[1.02–1.85]
≥1 and ≤3		1.73[1.32–2.25]	1.68[1.28–2.19]
<1		2.31[1.75–3.05]	2.10[1.59–2.78]
Geographic region
South		1.00	1.00
Southeast		1.09[0.94–1.26]	1.08[0.93–1.25]
Midwest		1.07[0.92–1.25]	1.03[0.88–1.21
North		1.050.90–1.22]	0.99[0.85–1.15]
Northeast		1.30[1.13–1.50]	1.23[1.07–1.41]
Results of health and behavior
Loss of ≥ 13 teeth
No			1.00
Yes			0.52[0.43–0.63]
Limited capacity to eat
Absent			1.00
Present			5.63[4.72–6.72]
Tooth brushing
≥2 times a day			1.00
<2 times a day			1.71[1.40–2.11]
Dental appointment in the last 12 months
Yes			1.00
No			1.30[1.18–1.43]
Self-rated health
Positive			1.00
Negative			2.68[2.40–3.00]

**Value of minimum salary (SM) in 2019: BRL 998.00. Source: Instituto Brasileiro de Geografia e Estatística. PNS 2019.

Likewise for men, the study showed among women, after adjusting for demographic and socioeconomic variables, there was also less association in the groups of informal workers (OR = 1.21; 95% CI = 1.08–1.35) and unemployed workers (OR = 1.47; 95% CI = 1.23–1.77). The magnitude of positive association with the main exposure was once again observed when the model was adjusted for the variables health and behavior, maintaining significance for both categories when compared to the reference (OR = 1.13; 95% CI = 1.00–1.27) for informal work, and (OR = 1.33; 95% CI = 1.09–1.61 for unemployment. Unemployed, middle-aged women, with low education level and low income, non-white race/color, residing in the Northeast region of the country, and with worse results in health were more likely to have a negative self-perception of oral health (Table 4).

Table 4

Multivariate analysis evaluating the socioeconomic, demographics, and health factors in the Negative SEOH among adult female Brazilians, according to data from the PNS, Brazil, 2019

Variables	OR (95% CI) Not	OR (95% CI) Model	OR(95% CI) Model
	adjusted	adjusted by	adjusted by socioeconomic,
		socioeconomic and	demographic, and health
		demographic variables	variables
Insertion in the labor market
Formal Employment	1.00	1.00	1.00
Informal Employment	1.68[1.52–1.87]	1.21[1.08–1.35]	1.13[1.00–1.27]
Unemployment	2.01[1.69–2.39]	1.47[1.23–1.77]	1.33[1.09–1.61]
Socioeconomic and demographic conditions
Age (years)
18-34		1.00	1.00
35-44		1.31[1.16–1.49]	1.21[1.06–1.38]
45-59		1.64[1.43–1.88]	1.26[1.09–1.45]
≥60		1.53[1.23–1.92]	1.10[0.86–1.40]
Race/Color
White		1.00	1.00
Non-white		1.28[1.13–1.45]	1.22[1.08–1.39]
Level of education
Higher Education		1.00	1.00
High School		1.32[1.12–1.56]	1.20[1.02–1.42]
Elementary		1.86[1.53–2.25]	1.61[1.32–1.97]
No formal education		1.90[1.59–2.27]	1.40[1.16–1.68]
Per capita household income in SM**
>6		1.00	1.00
>3 and ≤6		1.53[1.02–2.29]	1.40[0.93–2.01]
≥1 and ≤3		2.57[1.76–3.74]	2.27[1.55–3.31]
<1		3.87[2.62–5.70]	2.98[2.02–4.41]
Geographic region
South		1.00	1.00
Southeast		1.04[0.89–1.21]	1.05[0.90–1.22]
Midwest		1.23[1.02–1.47]	1.26[1.05–1.51]
North		1.01[0.85–1.20]	1.04[0.88–1.23]
Northeast		1.44[1.24–1.68]	1.43[1.23–1.66]
Health situation
Loss of ≥ 13 teeth
No			1.00
Yes			0.66[0.55–0.81]
Limited capacity to eat
Absent			1.00
Present			5.38[4.56–6.35]
Dental appointment in the last 12 months
Yes			1.00
No			1.37[1.22–1.53]
Self-rated health
Positive			1.00
Negative			2.53[2.27–2.81]

**Value of minimum salary (SM) in 2019: BRL 998.00. Source: Instituto Brasileiro de Geografia e Estatística. PNS 2019.

In the multivariate model adjusted for socioeconomic and demographic conditions, place of residency, and living with a spouse lost statistical significance for both genders. In the final multivariate model, race/color lost significance for men and “tooth brushing for women (Tables 3 and 4).

4 Discussion

The prevalence of negative self-perception of oral health found in the economically active population is lower than what was found in a study conducted in 2013, with the Brazilian population aged 18 years or older [16]. That study included economically inactive participants, that is, people that were outside the labor market, generally with a younger age profile. This characteristic is possibly an element for interpreting the differences indicated. Moreover, generational evolution cannot be ignored, as will be discussed later. Reinforcing the main thesis of this study, a greater chance of negative self-perception of oral health in informal workers, both male and female, was identified. Such results, which are representative of the Brazilian population, run in line with the literature. Self-perception of oral and general health is related to socioeconomic factors that influence the position of people in the social pyramid [4 –8]. Authors interested in investigating the relations between health and socioeconomic status have focused on education, income, and occupations [6 , 16–18]. This approach is consonant to the growing concerns related to massive unemployment in Brazil [19] and its consequent drawbacks, including a higher likelihood of poor health conditions [20]. Many characteristics related to the type of work are determinants of health. In a standard job, the relationship between employer and employee is formal, and labor rights, such as vacations and inspections of the work environment, are formally defined [10, 21]. Furthermore, the contract establishes the value of the salary and the access to welfare, such as the right to take time off for treatment and recovery of one’s ability to work while still receiving one’s income. This kind of contract was well established until the middle of the 20^th century. Political and economic changes, which began in the 1970 s, resulted in the growth of informal workers [22]. More than 40% of the employed Brazilians were in that situation in 2019 [23].

Although consistent about the positive relation between type of work (formal versus informal) and Self-perception of general health [24, 25], the literature is scarce in terms of results of self-perception of oral health in research focusing on the workforce. However, knowledge about one’s self- perception of health in general could guide interpretation of results presented, after acknowledging the two-way relation between general health and oral health [5, 6]. In this sense, if formal employment grants access to a range of resources that are deemed indispensable for the general health of individuals, it is plausible that the same gains would also benefit oral health [26]. In turn, informal employment produces situations of insecurity and exposure to unhealthy working environments [8, 27]. Such factors have been associated with a higher prevalence of accidents, absenteeism, and diseases [8, 10], including a worse SEOH [24, 27]. In informal employment, for instance, besides the restriction of breaks, the extended daily and weekly shifts limit the time required for self-care, such as flossing teeth and searching for dental care. Together, these factors affect the way people perceive their oral health. Another plausible explanation is the relation between informal work and smoking or alcohol abuse. These behaviors were associated with a lower frequency of tooth brushing [28].

Self-reported unemployment increased the chance of a negative self-perception of oral health among women; however, the same effect was not observed among men. Why is there a difference? Results from the literature on the insertion in the labor market, gender, and self-perception of oral health are scarce. Nonetheless, the literature indicates a higher prevalence of caries, periodontal disease, and tooth loss among unemployed women [4, 29]. In a study conducted in Finland, prolonged unemployment compared to recent unemployment was associated with worse oral health conditions among women [12]. Considering gender discrimination in the labor market, would unemployed women from the sample used in this study be in that situation for longer when compared to unemployed men? It is known that unemployment crisis in recent years has affected women much more than men [14]. Such results indicate possibilities for future studies since the duration of unemployment was not considered as a variable in the present study.

Moreover, the literature has controversial results regarding gender differences. While the study by Mendonça et al. [18] identified a higher prevalence of negative self-perception of oral health among women, Sousa et al. [7] presented studies that found no significant gender differences in self-perception of oral health results in the general population.

Reinforcing previous evidence, men and women who reported not having seen a dentist in the last 12 months had a higher chance of a negative SEOH [7 , 30]. There are at least two hypotheses that contribute to interpretation of this result. First, a better self-perception is associated with chance to be included in preventive actions, and consequently, having better oral health results. Access to dental services and professionals promotes general welfare with positive effects on the adoption of healthy practices, which would improve health results leading to positive perception of oral health. Informal workers or unemployed individuals lack access to dental care when compared to formal workers, due to the insufficient offer of care in the public health system and the high cost of private treatment [26]. It is worth mentioning that problems in access to preventive services and specialized treatments are among the main causes of poor oral health conditions [16].

The present study has limitations to be considered when interpreting the presented results. The possibility of information bias cannot be ruled out, since, firstly, social acceptance influences the response when participants are asked about healthy behaviors, for example, it is common for people to answer that they brush their teeth three times a day, although they do not, just because they recognize that this would be the most correct or socially acceptable response. If so, our results were underestimated. Although we know that the effects of tooth loss may vary depending on the quantity and region in which they occur, it is important to highlight that, due to the nature of the study based on national epidemiological data, data on the location of missing teeth were notcollected.

Is tooth loss among older people less negative than for younger people in the AASB? Stratification by age group reinforces this hypothesis, since the variable tooth loss (≥13) was associated with a greater chance of negative SEOH among younger individuals when compared to older individuals. These findings can be explained by a reduction in expectations regarding the health of individuals in the last stages of life, as the fact that they have already survived until that stage represents a positive state of health for them. Additionally, older people may have experienced long and intense episodes of pain and suffering caused by oral diseases, with tooth loss being considered a relief or the end of suffering. Culturally, the loss of teeth among the elderly is more accepted, since the idea that the elderly will naturally be without teeth still prevails. Another plausible explanation is that extensive tooth loss, although catastrophic for adolescents and young adults, may be mediated by dentures in the elderly.

Some strengths in this research deserve mention. The classification of the answers about insertion in the labor market when type of work (formal or informal) was included, prevented the employment versus unemployment dichotomy. Instead of studying one specific group of workers from a given productive sector of the economy, the respondents comprise the entire working class, since the household survey has a nationwide scope. The treatment of information collected in household surveys by calculating sampling weights improved consistency of associations found, since over-representations of individuals with identical characteristics, including working conditions, were avoided. It is also important to mention the advantages of the sample size for the analyses, which mitigates possible confounding factors. Moreover, the probabilistic sample calculation enables generalizing the obtained results.

The association between informal employment and negative self-perception of oral health is relevant in the Brazilian context of deregulation of work and increased number of people with no access to formal employment. The results suggest the work conditions should be approached in oral health promotion actions for adults, with emphasis on gender differences.

5 Conclusion

The results confirmed the initial hypothesis of this study: men and women precariously linked to the workforce had a greater chance of negative SEOH. Unemployed women are more likely to evaluate their oral health at higher levels, whereas this association was not observed among men. The association between informal work and negative SEOH is relevant in the Brazilian context of work deregulation and growth in the number of people without access to formal employment. The results suggest addressing employment conditions in actions to promote oral health among adults, with emphasis on gender differences.

Ethical approval

Not applicable.

Informed consent

Not applicable.

Dataset

The authors declare that the anonymized dataset supporting the results of this study is publicly available in the “Microdados IBGE” repository at the following address: https://www.pns.icict.fiocruz.br/bases-de-dados/.

Conflict of interest

There is no conflict of interest.

Footnotes

Acknowledgments

Not applicable.

Funding

There is no funding.

References

Baiju

Peter

Varghese

Sivaram

. Oral Health and Quality of Life: Current Concepts. J Clin Diagn Res. 2017;11(6):ZE21ZE26–.

Thomson

Elani

. Self-report oral health and disease experience among adults in China and NZ. Clin Oral Invest. 2019;23(5):2123–28.

Matos

Lima-Costa

. Auto-avaliação da saúde bucal entre adultos e idosos residentes na Região Sudeste: resultados do Projeto SB-Brasil, 2003. Cad. Saúde Pública. 2006;22(8):1699–707.

Luchi

Peres

Bastos

Peres

. Desigualdades na autoavaliação da saúde bucal em adultos. Rev. Saúde Pública. 2013;47(4):740–51.

Hakeberg

Boman

. Self-reported oral and general health in relation to socioeconomic position. BMC Public Health. 2018;18(1):1–8.

Sabbah

Tsakos

Chandola

Sheiham

Watt

. Social gradients in oral and general health. J Dent Res. 2007;86(10):992–96.

Sousa

Henriques

Silva

Severo

Silva

. Posição socioeconômica e autoavaliação da saúde bucal no Brasil: resultados da Pesquisa Nacional de Saúde. Cad. Saúde Pública. 2019;35(6):1–13.

Guarnizo-Herreño

CCH

Watt

Fuller

Steele

Shen

Morris

, et al.Socioeconomic position and subjective oral health: findings for the adult population in England, Wales and Northern Ireland. BMC Public Health. 2014;14:827.

Burdorf

. The importance of solid employment for health. Scand J Work Environ Health. 2008;34(2):81–2.

10.

Lund

Alfers

Santana

. Towards an inclusive occupational health and safety for informal workers. New Solut. 2016;26(2), 190–207.

11.

Portero de la Cruz

Cebrino

. Trends in diet quality and related sociodemographic, health, and occupational characteristics among workers in Spain: Results from three consecutive national health surveys (2006-2017). Nutrients. 2021;13(2).

12.

Al-Sudani

Vehkalahti

Suominen

. The association between current unemployment and clinically determined poor oral health. Community Dent Oral Epidemiol. 2015;43(4):325–37.

13.

Molarius

Engström

Flink

, et al.Socioeconomic differences in self-rated oral health and dental care utilisation after the dental care reform in 2008 in Sweden. BMC Oral Health. 2014;14:134.

14.

Fernandez

BPM

. Teto de vidro, piso pegajoso e desigualdade de gênero no mercado de trabalho brasileiro à luz da economia feminista: por que as iniquidades persistem?. Rev. Cadernos de Campo. 2019;(26):79–104.

15.

Instituto Brasileiro de Geografia e Estatística (IBGE). Saúde. Pesquisa Nacional de Saúde. Accessed on May 28, 2022. Available at https://www.ibge.gov.br.

16.

Nico

Andrade

SSCDA

Malta

Pucca

Peres

. Saúde Bucal autorreferida da população adulta brasileira: resultados da Pesquisa Nacional de Saúde 2013. Ciênc. Saúde Colet. 2016;21:389–98.

17.

Borrell

Taylor

Borgnakke

Woolfolk

Nyquist

. Perception of general and oral health in White and African American adults: assessing the effect of neighborhood socioeconomic conditions. Community Dent Oral Epidemiol. 2004;32(5):363–73.

18.

Mendonça

Szwarcwald

Damacena

. Autoavaliação da saúde bucal: resultados da Pesquisa Mundial de Saúde-Atenção Básica em quatro municípios do Estado do Rio de Janeiro, Brasil, 2005. Cad. Saúde Pública. 2012;28, 1927–38.

19.

Costa

SDS

. Pandemia e desemprego no Brasil. Rev Adm Pública. 2020;54, 969–78.

20.

Gray

Grey

CNB

Hookway

Homolova

Davies

A R

. Differences in the impact of precarious employment on health across population subgroups: a scoping review. Pers Public Health. 2021;141(1):37–49.

21.

Benach

Vives

Amable

Vanroelen

Tarafa

Muntaner

. Precarious employment: understanding an emerging social determinant of health. Annu Rev Public Health. 2014;35, 229–53.

22.

Ulyssea

. Informality in the labor market: a review of the literature. BJPE. 2006;26(4):596–618.

23.

Instituto Brasileiro de Geografia e Estatística (IBGE). Indicadores. Pesquisa Nacional por Amostra de Domicílios Contínua – PNAD Contínua. Principais destaques da evolução do mercado de trabalho no Brasil 2012-2020. Accessed on May 28, 2022. Available at https://www.ibge.gov.br.

24.

Kwon

Park

Lee

K-J

Cho

Y-S

. Association between employment status and self-rated health: Korean working conditions survey. Ann Occup Environ Med. 2016;28(1):43.

25.

Vancea

Utzet

. How unemployment and precarious employment affect the health of young people: A scoping study on social determinants. Scand J Public Health. 2017;45(1):73–84.

26.

Gallego

Larroulet

Palomer

Repetto

Verdugo

. Socioeconomic inequalities in self-perceived oral health among adults in Chile. Int J Equity Health. 2017;16(1):23.

27.

Okunseri

McGrath

Wong

. Self-Reported General and Oral Health in Adults in the United States: NHANES 1999-2014. Clin Cosmet Investig Dent. 2019;11, 399–408.

28.

Harada

Takeuchi

Furuta

, et al.Gender-dependent associations between occupational status and untreated caries in Japanese adults. Ind Health. 2018;56(6):539–44.

29.

Hamasha

AAH

Alshehri

Alshubaiki

Alssafi

Alamam

Alshunaiber

. Gender-specific oral health beliefs and behaviors among adult patients attending King Abdulaziz Medical City in Riyadh. Saudi Dent J. 2018;30(3):226–31.

30.

Silva

JV da

Oliveira

AGR da C

. Individual and contextual factors associated to the self-perception of oral health in Brazilian adults. Rev Saúde Pública. 2018;9;52:29.

Variables		Percentage*
	Total sample	Male	Female	p-value
SEOH
Positive	70.7	69.0	72.8	< 0.001
Negative	29.3	31.0	27.2
Insertion in the labor market
Formal Employment	43.4	44.7	41.9	< 0.001
Informal Employment	48.4	49.0	47.6
Unemployment	8.2	6.3	10.5
Socioeconomic and demographic conditions
Age (years)
18–34	38.4	38.6	38.2	0.002
35–44	25.5	24.4	26.8
45–59	28.1	28.3	27.8
≥60	8.1	8.7	7.2
Race/Color
White	42.3	40.9	44.0	< 0.001
Non-white	57.7	59.1	56.0
Level of education
Higher education	18.7	14.9	23.2	< 0.001
High School	40.4	38.2	42.8
Elementary	15.1	16.9	12.9
No formal education	25.9	30.0	21.0
Per capita household income in SM**
>6	3.6	3.4	3.7	0.726
>3 and ≤6	7.9	7.9	8.0
≥1 and ≤3	41.4	41.4	41.5
<1	47.1	47.3	46.8
Geographic region
South	14.8	14.8	14.9	< 0.001
Southeast	44.7	43.4	46.2
Midwest	8.1	8.1	8.0
North	7.9	8.4	7.2
Northeast	24.6	25.4	23.7
Area of residency
Urban	87.7	84.8	91.1	< 0.001
Rural	12.3	15.2	8.9
Lives with spouse
Yes	63.2	69.1	56.4	< 0.001
No	36.8	30.9	43.6
Results of health and behavior
Loss of ≥ 13 teeth
No	93.1	94.0	92.2	< 0.001
Yes	6.9	6.0	7.8
Limited capacity to eat
Absent	90.9	92.1	90.0	< 0.001
Present	9.1	7.9	10.0
Tooth brushing				< 0.001
≥2 times a day	96.3	94.5	98.4
<2 times a day	3.7	5.5	1.6
Dental appointment in the last 12 months
Yes	53.1	47.0	60.2	< 0.001
No	46.9	53.0	39.8
Self-rated health
Positive	73.2	76.0	69.9	< 0.001
Negative	26.8	24.0	30.1