Effect of the 2008 economic crisis on oral health in Spain: analysis of serial cross-sectional, population-based health surveys

Abstract

Objectives

To evaluate the impact of the economic crisis on the oral health of individuals in Spain based on variables including sex, unemployment, social class and educational level.

Design

This was an analysis of serial cross-sectional, population-based health surveys conducted before the crisis (2003 and 2006) and during the crisis (2011, 2014 and 2017).

Setting

National Health Surveys of Spain and the European Health Survey in Spain.

Participants

A total of 189 543 participants were recruited.

Outcome measures

The independent variables were sex, employment, social class and educational level. The dependent variables were related to oral health. Descriptive statistics, χ² tests and the Cochran-Mantel-Haenszel test were performed.

Results

The results showed that there were differences (p<0.001) in all oral health indicators before and after the crisis. Compared with the precrisis period, men had a higher probability of tooth extractions (OR 1.41, 95% CI 1.37 to 1.45), dental fillings (OR 1.30, 95% CI 1.27 to 1.34), prostheses (OR 1.04, 95% CI 1.01 to 1.07) and missing teeth (OR 1.35, 95% CI 1.31 to 1.39). Unemployed individuals were more likely to have dental caries (OR 1.08, 95% CI 1.00 to 1.16) and missing teeth (OR 1.36, 95% CI 1.27 to 1.46). Working class individuals had a higher probability of tooth extractions (OR 1.63, 95% CI 1.59 to 1.67), bleeding gums (OR 1.04, 95% CI 1.01 to 1.07), prostheses (OR 1.05, 95% CI 1.02 to 1.07) and missing teeth (OR 1.36, 95% CI 1.33 to 1.39). Participants with a basic or intermediate level of education had a higher probability of dental mobility (OR 1.13, 95% CI 1.07 to 1.19), prostheses (OR 1.11, 95% CI 1.08 to 1.14) and missing teeth (OR 1.42, 95% CI 1.38 to 1.46).

Conclusions

The economic crisis affected the oral health of the Spanish population, with a more significant deterioration among men, working class individuals and unemployed individuals.

Correspondence to Dr Rosa Rojo; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• A series of national oral health surveys were conducted in Spain before and during the 2008 economic crisis. This is a strength as this study analysed the results in two different periods.

• Surveys were conducted through computer-assisted personal interviews, which is a strength since prevented data loss and improved the selection of participants.

• A representative sample of the population over 15 years of age is a strength since an adequate number of participants was used.

• Data were self-reported by participants, which is a limitation, as the data were subjective.

• Studying the influence of sex, employment, social class and level of education is a strength since it included the analysis of multivariate models.

Introduction

Economic crises affect the health of individuals, and some of the factors that influence their impacts are related to the social protection model of each country and the measures adopted by governments to combat the recession.^{1 2} It is widely recognised that there is a relationship between the economy and the population’s health; thus, crises can have negative consequences on healthcare.^3–5

The Spanish public health system offers limited dental care for individuals with acute pathology who are over 16 years of age. There is public funding for preventive and restorative treatments for children. However, other dental procedures are provided through private entities, which necessitates an additional cost for households.^{6 7}

Periods of economic instability are associated with unemployment, lower incomes, problems with public financing and problems with healthcare access.⁸ During the 2008 economic crisis in Europe, the use of healthcare became more restrictive. In Spain, all macroeconomic indicators, including employment, national income and gross domestic product (GDP), fell. The GDP before the crisis in 2003 and 2006 was 3.0 and 4.1, respectively, and after the crisis, in 2011, 2014 and 2017, it fell to negative values of −0.8, 1.4 and 3.0, respectively.⁹ This contributed to inequalities in access to dental care and less access for the most vulnerable socioeconomic groups.¹⁰ For example, the average unemployment rates before the crisis in 2003 and 2006 were 11.5% and 8.5%, respectively. After the crisis, in 2011, 2014 and 2017, these rates were higher at 21.4%, 24.4% and 17.2%, respectively. Higher education levels in 2003 and 2006 were 3.5% and 3.3%, respectively. After the crisis, they were similar in 2011, 2014 and 2017, at 3.4%, 3.3% and 3.4%, respectively. High school and intermediate education levels in 2003 and 2006 were 16.2% and 15.7%, respectively. After the crisis, in 2011, 2014 and 2017, these rates were higher at, 16.8%, 17.4% and 17.5%, respectively.¹¹

The effects of the austerity policies of the 2008 economic crisis have been analysed in European countries with universal health coverage, such as Germany, the UK, Ireland, Latvia, Greece and Spain, and an increase in the number of suicides and dissatisfaction with healthcare was found.^{1 12}

The aim of this study was to evaluate the impact of the economic crisis in Spain on oral health based on variables such as sex, unemployment, social class and educational level.

Methods

A population-based cross-sectional series study was conducted following the Strengthening the Reporting of Observational studies in Epidemiology¹³ guidelines.

Setting and participants

The data were obtained from the National Health Surveys (NHSs) of Spain for the years 2003 (from April 2003 to March 2004), 2006 (from June 2006 to June 2007), 2011 (from July 2011 to June 2012),¹⁴ 2017 (from October 2016 to October 2017)¹⁵ and the 2014 European Health Survey (EHS) in Spain (from January 2014 to January 2015).¹⁶ The databases used belong to the National Institute of Statistics of Spain (https://www.ine.es/dyngs/INEbase/es/categoria.htm?c=Estadistica_P&cid=1254735573175) and are accessible for public use.^14–16

The target population of this study was people residing in family homes in Spanish territory. When of two or more families lived in a dwelling, the study was extended to include all of them, but each family was still considered independently. The data were self-reported.

For data collection, a computer-assisted personal interview was carried out (a face-to-face interview in which the interviewer used software that navigated through the questionnaire, generated flows and may even have had consistency validations), which was complemented, when necessary and in exceptional cases, by a telephone interview. At the time of the interview, the participants have consent to participate in this study, and the approval of an ethics committee was not necessary since the data were anonymised and for public use. The NHSs of Spain were carried out by the Ministry of Health, Consumption and Social Welfare in collaboration with the National Institute of Statistics. The EHS in Spain was carried out by the Ministry of Health, Social Services and Equality, and National Institute of Statistics three-stage sampling was used. The first-stage units were the census sections. The second-stage units were the primary family dwellings, which involved investigating all the households with their habitual residents. To estimate the characteristics of the population, ratio estimators were used to which calibration techniques were applied, taking as auxiliary variables the age and sex groups and nationality groups of the population of the autonomous community. Finally, adults aged 15 years and older were included in the group. Within each household, an adult (15 years or over) was selected. The third-stage units were selected from the list of surveyable individuals in the dwelling at the time of the interview. The exclusion criteria were as follows: the selected person was admitted to a hospital or residence; the selected person was unable to answer due to severe illness or disability or the selected person could not answer because of the language.

The sample size was calculated by the National Institute of Statistics. The datasets and other methodological details are accessible for public use.^14–16 The current study data are available from the corresponding author on reasonable request.

Patient and public involvement

Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Variables

The absolute frequency data from the databases were used, and the variables were recoded to homogenise the results of each survey. For the analyses, the gdp of Spain was used to group the data in the periods before the crisis and during the crisis. The surveys carried out in 2003 and 2006 corresponded to the period before the crisis, and the surveys carried out in 2011, 2014 and 2017 corresponded to the period during the crisis.

All the variables collected were categorical. The independent variables were sex (male/female), employment (workers: employed, working/unemployed), social class (the upper class included class I: directors and managers of establishments with ten or more salaried and traditionally associated with university degrees; class II: directors and managers of establishments with fewer than 10 employees, professionals traditionally associated with university degrees and other technical support professionals, athletes and artists; class III: intermediate employers and self-employed workers; class IV: supervisors and workers in skilled technical fields; class V: skilled workers in the primary sector and other semiskilled workers and class VI: unskilled workers) and level of education (higher level of education: university studies or equivalent; basic or intermediate level of education: training professional, high school and secondary education). The dependent variables were related to oral health and included the following: (1) dental caries (cavities were present as erosion of the enamel and ivory of the teeth/molars by the action of certain bacteria), (2) tooth extraction (teeth/molars were extracted), (3) dental fillings (filled teeth/molars), (4) bleeding gums (the gums bled when brushing or spontaneously), (5) tooth mobility (the teeth/molars had moved), (6) prostheses (crowns, bridges, other types of prostheses or dentures were worn), (7) missing teeth (teeth/molars were missing and not replaced by prostheses) and (8) preservation of all teeth (individuals had all natural teeth/molars).

Statistical methods

Descriptive statistics included calculating the frequencies and percentages of each variable. Missing data were not included in the data analysis; only complete cases were evaluated. Oral health variables before the crisis and after the crisis were analysed with a χ² test. To evaluate the relationship between the independent variables (sex, employment, social class and educational level) and the oral health variables, the Cochran-Mantel-Haenszel test was used. R Studio V.1.1.456 was used for all tests. The values were considered statistically significant at p<0.05.

Results

A total of 189 543 patients from the precrisis surveys (n=72 789) and the surveys during the crisis period (n=116 754) were analysed.

The oral health indicators evaluated in each of the surveys are shown in table 1. Depending on the period, before the crisis or during the crisis, statistically significant differences (p<0.001) in all oral health indicators (presence of dental caries, tooth extractions, dental fillings, bleeding gums, tooth mobility, prostheses, missing teeth and preservation of all teeth) (online supplemental table 1) were observed in the results.

Table 1

Oral health indicators in the 2003, 2006 (precrisis) 2011, 2014 and 2017 (during the crisis) surveys

	2003			2006			2011			2014			2017
	n	Yes (%)	No (%)	n	Yes (%)	No (%)	n	Yes (%)	No (%)	n	Yes (%)	No (%)	n	Yes (%)	No (%)	P value
Dental caries	35 361	9964 (28.18)	25 397 (71.82)	37 428	10 491 (28.03)	26 937 (71.97)	38 726	10 624 (27.43)	28 102 (72.57)	38 959	9692 (24.88)	29 267 (75.12)	39 069	8409 (21.52)	30 660 (78.48)	<0.001
Tooth extractions		24 778 (70.07)	10 583 (29.93)		26 620 (71.12)	10 808 (28.88)		27 202 (70.24)	11 524 (29.76)		28 202 (72.39)	10 757 (27.61)		28 640 (73.31)	10 429 (26.69)	<0.001
Dental fillings		21 664 (61.27)	13 697 (38.73)		23 971 (64.05)	13 457 (35.95)		25 137 (64.91)	13 589 (35.09)		24 903 (63.92)	14 056 (36.08)		26 273 (67.25)	12 796 (32.75)	<0.001
Bleeding gums		5367 (15.18)	29 994 (84.82)		7970 (21.29)	29 458 (78.71)		6571 (16.97)	32 155 (83.03)		6837 (17.55)	32 122 (82.45)		6446 (16.50)	32 623 (83.50)	<0.001
Tooth mobility		1972 (5.58)	33 389 (94.42)	37 429	2769 (7.40)	34 659 (92.60)		2385 (6.16)	36 341 (93.84)		2505 (6.43)	36 454 (93.57)		1992 (5.10)	37 077 (94.90)	<0.001
Prostheses		13 498 (38.17)	21 863 (61.83)	37 428	14 777 (39.48)	22 651 (60.52)		15 141 (39.10)	23 585 (60.90)		15 459 (39.68)	23 500 (60.32)		15 375 (39.35)	23 694 (60.65)	0.065
Missing teeth		16 293 (46.08)	19 068 (53.92)		17 774 (47.49)	19 654 (52.51)		19 245 (49.70)	19 481 (50.30)		21 262 (54.58)	17 697 (45.42)		22 323 (57.14)	16 746 (42.86)	<0.001
Preservation of all teeth		26 935 (76.17)	8426 (23.83)		7590 (20.28)	29 838 (79.72)		9211 (23.79)	29 515 (76.21)		10 163 (26.09)	28 796 (73.91)		10 418 (26.67)	28 651 (73.33)	<0.001

The pvalues show the results of the χ² test before the crisis (2003 and 2006) vs during the crisis (2011, 2014 and 2017).

The influence of sex, employment status, social class and level of education on oral health indicators in the years prior to the crisis and during the crisis are shown in table 2.

Table 2

Cochran-Mantel-Haenszel test to assess the relationship of oral health before the crisis and during the crisis with sex, employment status, social class and level of education

	Dental caries OR (95% CI)	Tooth extractions OR (95% CI)	Dental fillings OR (95% CI)	Bleeding gums OR (95% CI)	Tooth mobility OR (95% CI)	Prostheses OR (95% CI)	Missing teeth OR (95% CI)	Preservation of all teeth OR (95% CI)
Males	0.93 (0.90 to 0.96)***	1.41 (1.37 to 1.45)***	1.30 (1.27 to 1.34)***	1.02 (0.99 to 1.06)	0.90 (0.85 to 0.95)***	1.04 (1.01 to 1.07)**	1.35 (1.31 to 1.39)***	1.07 (1.04 to 1.10)***
Females	0.90 (0.87 to 0.92)***	1.21 (1.17 to 1.24)***	1.23 (1.20 to 1.27)***	0.94 (0.91 to 0.97)***	0.88 (0.83 to 0.93)***	0.98 (0.95 to 1.00)**	1.25 (1.22 to 1.28)***	1.33 (1.29 to 1.37)***
Cochran-Mantel-Haenszel test results	0.91 (0.89 to 0.93)***	1.31 (1.28 to 1.33)***	1.27 (1.24 to 1.29)***	0.98 (0.96 to 1.00)	0.89 (0.86 to 0.92)***	0.99 (0.86 to 1.03)	1.30 (1.27 to 1.32)***	1.19 (1.16 to 1.21)***
Workers	0.86 (0.84 to 0.89)***	1.55 (1.51 to 1.59)***	1.68 (1.64 to 1.73)***	0.87 (0.82 to 0.92)***	0.87 (0.82 to 0.92)***	1.09 (1.06 to 1.12)***	1.29 (1.26 to 1.32)***	1.08 (1.05 to 1.12)***
Unemployed individuals	1.08 (1.00 to 1.16)*	1.41 (1.31 to 1.51)***	1.26 (1.17 to 1.35)***	1.06 (0.92 to 1.21)	1.06 (0.92 to 1.21)	0.98 (0.91 to 1.06)	1.36 (1.27 to 1.46)***	1.06 (0.98 to 1.15)
Cochran-Mantel-Haenszel test results	0.89 (0.87 to 0.91)***	1.53 (1.49 to 1.57)***	1.62 (1.58 to 1.66)***	0.90 (0.85 to 0.95)***	0.90 (0.85 to 0.95)***	1.08 (1.05 to 1.10)***	1.30 (1.27 to 1.33)***	1.08 (1.05 to 1.11)***
Upper class	0.84 (0.81 to 0.87)***	1.44 (1.40 to 1.48)***	1.58 (1.53 to 1.63)***	1.01 (0.97 to 1.05)	0.74 (0.69 to 0.79)***	0.97 (0.94 to 1.00)*	1.17 (1.14 to 1.21)***	1.36 (1.32 to 1.40)***
Working class	0.99 (0.96 to 1.01)	1.63 (1.59 to 1.67)***	1.43 (1.39 to 1.46)***	1.04 (1.01 to 1.07)**	0.94 (0.89 to 0.98)**	1.05 (1.02 to 1.07)***	1.36 (1.33 to 1.39)***	1.11 (1.08 to 1.14)
Cochran-Mantel-Haenszel test results	0.93 (0.91 to 0.95)***	1.53 (1.51 to 1.57)***	1.48 (1.46 to 1.51)***	1.03 (1.01 to 1.05)*	0.86 (0.83 to 0.90)***	1.01 (0.99 to 1.03)	1.28 (1.26 to 1.30)***	1.21 (1.19 to 1.24)***
Higher level of education	1.13 (1.05 to 1.22)***	1.72 (1.62 to 1.81)***	1.86 (1.75 to 1.97)***	1.44 (1.33 to 1.57)***	0.96 (0.82 to 1.13)	0.89 (0.83 to 0.94)***	1.33 (1.25 to 1.41)***	1.16 (1.08 to 1.23)***
Basic or intermediate level of education	1.02 (0.99 to 1.04)	1.69 (1.65 to 1.73)***	1.41 (1.38 to 1.45)***	1.32 (1.28 to 1.37)***	1.13 (1.07 to 1.19)***	1.11 (1.08 to 1.14)***	1.42 (1.38 to 1.46)***	1.00 (0.97 to 1.03)
Cochran-Mantel-Haenszel test results	1.03 (1.00 to 1.06)*	1.69 (1.65 to 1.73)***	1.48 (1.47 to 1.50)***	1.34 (1.30 to 1.38)***	1.11 (1.06 to 1.17)***	1.07 (1.05 to 1.10)***	1.41 (1.37 to 1.44)***	1.02 (1.00 to 1.05)

*p<0.05, **p<0.01, ***p<0.001.

Oral health evaluation between the periods according to sex

Men had a significantly higher probability of tooth extractions (OR 1.41, 95% CI 1.37 to 1.45), dental fillings (OR 1.30, 95% CI 1.27 to 1.34), prostheses (OR 1.04, 95% CI 1.01 to 1.07) and missing teeth (OR 1.35, 95% CI 1.31 to 1.39). However, women were more likely to have preserved teeth (OR 1.33, 95% CI 1.29 to 1.37) and less likely to have dental caries (OR 0.90, 95% CI 0.87 to 0.92).

Oral health evaluation between the periods according to employment status

Unemployed individuals were significantly more likely to have dental caries (OR 1.08, 95% CI 1.00 to 1.16) and missing teeth (OR 1.36, 95% CI 1.27 to 1.46). However, employed individuals had a higher probability of tooth extractions (OR 1.55, 95% CI 1.51 to 1.59), dental fillings (OR 1.68, 95% CI 1.64 to 1.73), prostheses (OR 1.09, 95% CI 1.06 to 1.12) and preservation of all teeth (OR 1.08, 95% CI 1.05 to 1.12), as well as a lower probability of tooth mobility (OR 0.87, 95% CI 0.82 to 0.92) and gum bleeding (OR 0.87, 95% CI 0.82 to 0.92).

Oral health evaluation between the periods according to social class

Working class individuals had a significantly higher probability of tooth extractions (OR 1.63, 95% CI 1.59 to 1.67), bleeding gums (OR 1.04, 95% CI 1.01 to 1.07), prostheses (OR 1.05, 95% CI 1.02 to 1.07) and missing teeth (OR 1.36, 95% CI 1.33 to 1.39). However, upper class individuals had a higher probability of preservation of all teeth (OR 1.36, 95% CI 1.32 to 1.40) and dental fillings (OR 1.58, 95% CI 1.53 to 1.63), as well as a lower probability of dental caries (OR 0.84, 95% CI 0.81 to 0.87) and dental mobility (OR 0.74, 95% CI 0.69 to 0.79).

Oral health evaluation between the periods according to education level

Participants with a basic or intermediate level of education had a significantly higher probability of dental mobility (OR 1.13, 95% CI 1.07 to 1.19), prostheses (OR 1.11, 95% CI 1.08 to 1.14) and missing teeth (OR 1.42, 95% CI 1.38 to 1.46). However, participants with a high level of education had a higher probability of preservation of all teeth (OR 1.16, 95% CI 1.08 to 1.23), gum bleeding (OR 1.44, 95% CI 1.33 to 1.57), dental fillings (OR 1.86, 95% CI 1.75 to 1.97) and dental caries (OR 1.13, 95% CI 1.05 to 1.22).

Discussion

The 2008 economic crisis in Spain negatively affected oral health indicators, with statistically significant differences between the periods before and during the crisis.

Accessibility to health services depends on individual factors, the social context and the health system.¹⁷ Our study considered the data available from the NHSs that included sex, employment status, social class and educational level. However, other studies that have evaluated the economic impact of the crisis on oral health have also included other factors, such as age, marital status or the presence of chronic diseases.^{18 19} Women have better oral health than men, and in general, women go to the dentist more often than men,²⁰ take better care of their teeth (ie, more frequent brushing and use of dental floss or fluoride tooth paste), more greatly value aesthetics and have better knowledge of oral health.^21–23 However, some studies show that men are more likely to brush and floss.²⁴ These differences may be because economic crises cause multifactorial health effects.^25–27 Our results are similar to those of another study carried out in Italy in which the impact of the 2008 economic crisis on oral health was assessed, and worse outcomes were observed among men and people with a low educational level.²⁸

Compared with unemployed individuals, employed individuals were less likely to develop periodontal disease (such as gum bleeding and tooth mobility), had more extractions and conservative treatments (such as fillings and prostheses) performed, and preserved their teeth better. Other studies show that employed individuals go to the dentist substantially more²⁰ than unemployed individuals; however, they are more prone to cavities.

In regard to social class, the working class was more likely to have dental extractions. However, the upper class had better oral health with better preservation of teeth and was less likely to present tooth mobility and cavities. These results are consistent with those of other studies in which a low income level negatively affected health.^29–31 In addition, study by Lopez-Valcarcel et al³² carried out in Spain showed that during the 2008 crisis, health problems worsened among people of in the most vulnerable population groups and the most disadvantaged social classes.

In regard to education level, negative oral health indicators were more balanced compared with the previous socioeconomic factors evaluated, such as sex, employment status and social class. Participants with a primary or intermediate level of education had a greater probability of tooth loss, tooth mobility and conservative treatments, such as the placement of dental prostheses. In the case of participants with a high level of education, although they had a greater probability of teeth preservation and conservative treatments such as fillings, they had a more substantial presence of cavities, bleeding gums and extractions. Other studies have shown that individuals with lower educational attainment are at higher risk for unmet dental needs.^{6 24 31}

One of the most critical limitations of this study is that the results were collected from self-report surveys, which included biases due to the subjectivity of the participants’ responses. For example, in the surveys, the variable that referred to preserved teeth did not indicate whether third molars were considered in the response. Therefore, the results must be interpreted with caution. In addition, in some publications, it has been observed that in periods of crisis, individuals tend to have more negative self-evaluations of health.^{4 5 33} Despite this bias, national surveys have been frequently used to assess the general state of the population, providing a representative sample size. In Spain, other self-report surveys were carried out to assess the economic crisis and health status among 44 138 participants. In our study, we included 189 543 respondents, and more socioeconomic factors were evaluated, but the results obtained were the same concerning the negative impact of the crisis on unemployed individuals and working class individuals.⁶ Additionally, it should be acknowledged that the variables collected concerning the missing teeth were included if the missing teeth were not restored. Therefore, the number of preserved teeth did not necessarily reflect the number of missing teeth.

Not all countries that experience crises observe a negative effect on the health of individuals. For example, in the case of Cyprus, the only report was that more patients had difficulties financing their health needs.³⁴ However, the most vulnerable social groups suffered devastating consequences in most European countries during the 2008 crisis.^{1 12 35 36}

This study suggests that the economic crisis affected the oral health of the Spanish population, had a negative impact on men, working class individuals and unemployed individuals, and did not significantly affect individuals differently based on their educational level.

Data availability statement

Data are available on reasonable request. The data details are accessible for public use. The current study are available from the corresponding author on reasonable request.

Ethics statements

Patient consent for publication

Not applicable.

Footnote

Contributors SME: data curation, guarantor and investigation; RR, formal analysis; SME, JS-R-M and AL: methodology and conceptualisation; AGdM, resources; JS-R-M and AL, supervision; JS-R-M, AGdM and AL: validation; SME and RR, visualisation and writing-original draft. All authors contributed to data interpretation, reviewed successive drafts and approved the final version of the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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