Community Dent Oral Epidemiol 2012; 40: 97104 All rights reserved

2011 John Wiley & Sons A/S

Social capital and self-rated oral health among young people

Furuta M, Ekuni D, Takao S, Suzuki E, Morita M, Kawachi I. Social capital and self-rated oral health among young people. Community Dent Oral Epidemiol 2012; 40: 97104. 2011 John Wiley & Sons A S Abstract Objectives: A few studies have revealed the impact of neighborhood social capital on oral health among young people. We sought to examine the associations of social capital in three settings (families, neighborhoods, and schools) with self-rated oral health among a sample of college students in Japan. Methods: Cross-sectional survey of 967 students in Okayama University, aged 18 and 19 years, was carried out. Logistic regression was used to examine the associations of poor self-rated oral health with perceptions of social capital, adjusting for self-perceived household income category and oral health behaviors. Results: The prevalence of subjects with poor self-rated oral health was 22%. Adjusted for gender, self-perceived household income category, dental fear, toothbrush frequency, and dental oss use, poor self-rated oral health was signicantly associated with lower level of neighborhood trust [odds ratio (OR) 2.22; 95% condence interval (CI): 1.403.54] and lower level of vertical trust in school (OR 1.71; 95% CI: 1.052.80). Low informal social control was unexpectedly associated with better oral health (OR 0.54; 95% CI: 0.34 0.85). Conclusion: The association of social capital with self-rated oral health is not uniform. Higher trust is associated with better oral health, whereas higher informal control in the community is associated with worse oral health.

Michiko Furuta1,2, Daisuke Ekuni1, Soshi Takao3, Etsuji Suzuki3, Manabu Morita1 and Ichiro Kawachi4
1 Department of Preventive Dentistry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan, 2Section of Preventive and Public Health Dentistry, Division of Oral Health, Growth and Development, Kyushu University Faculty of Dental Science, Fukuoka, Japan, 3 Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan, 4Department of Society, Human Development, and Health, Harvard School of Public Health, MA, USA

Key words: oral health; social sciences; social capital; young adult Daisuke Ekuni, Department of Preventive Dentistry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan Tel.: +81 86 235 6712 Fax: +81 86 235 6714 e-mail: dekuni7@md.okayama-u.ac.jp Submitted 22 March 2011; accepted 9 September 2011

Oral health shares many of the same risk factors and determinants as other chronic diseases such as cardiovascular disease (1), cancer (2), chronic respiratory disease (3), and diabetes (4). While much attention has been focused on the shared behavioral risk factors underlying oral health and other chronic diseases such as tobacco use, unhealthy diet, and excessive alcohol use there has been comparatively less research focused on the social determinants of oral health. Recent studies have begun to document that oral health status is associated with several social and contextual factors including socioeconomic status (SES), community income distribution, and social support social networks (59). An additional fact shared by oral diseases and other adult chronic diseases is that they often share early life course origins. That is, to understand the relationships between various risk factors and diseases in adulthood, it is necessary to trace back their developmental origins earlier in life. Thus,
doi: 10.1111/j.1600-0528.2011.00642.x

childhood and adolescence are critical periods during which many behavioral risk factors (such as dietary practices and smoking habits) become established. It is therefore important to understand the protective and damaging factors in the social environment of youth that may place them on differential health trajectories for the rest of their lives. Social capital is one such factor that has garnered increasing attention as a potential inuence on the development of youth. According to the sociologist James Coleman, social capital refers to the set of resources that inheres within family social relations as well as within community social organization and that are useful for the cognitive or social development of a child (10). Although Colemans writings were primarily focused on the role of social capital in childrens scholastic performance (human capital formation), subsequent research has expanded the range of outcomes to include health behaviors and population health outcomes (11).

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Although the optimal approach to capture the concept of social capital continues to be debated, most empirical research to date has included measures such as trust, cooperation, reciprocity, and exchange of social support between members of a group (11). Social capital theory posits that interpersonal trust, norms of reciprocity, and exchange of social support each constitutes a type of resource (i.e., capital) that inheres in tightly knit social relationships and that access to these resources may facilitate the actions of group members (11, 12). In the context of youth development, an adolescent who is a member of a tightly knit community may be inuenced in their subsequent development (including trajectories of health behavior) by the supervision, advice, and monitoring of other adults in the same group (13). Social capital theory simultaneously recognizes that the direction of social inuence in tightly knit collectives is not uniform in a health-promoting direction. Indeed, some groups with strong social capital could promote unhealthy (14) or deviant behavior (11) for example, a youth who belongs to a delinquent gang engaging in substance abuse. A few studies to date have reported that social capital is related with oral health in children and young people (5, 6, 8), and this association may be mediated by oral health behavior and buffering of stress (5, 6). These studies have primarily focused on neighborhood social capital. For young people, however, social capital is accessed not just through the neighborhoods in which they reside, but also from their families as well as their school peers (10, 15, 16). The objective of this study was to examine the associations between the self-rated oral health and social capital in the family, in the neighborhood, and at school among youth.

study was approved by the Ethics Committee of Okayama University. All subjects completed a survey inquiring about their self-assessed oral health status, as well as their perceptions of social capital in different settings (family, high school peers, neighborhoods). Participants over the age of 20 years were excluded, since more than a few years had elapsed since they graduated from high school. We additionally excluded participants with missing values on self-rated oral health and social capital indicators (family trust, neighborhood trust, informal social control, school trust, school reciprocity). Finally, the data of 967 students (677 men, 290 women) aged 18 and 19 were analyzed.

Dependent variable: self-rated oral health

The dependent variable was self-rated oral health status. Self-rated oral health is used frequently in epidemiological studies including national health surveys and is a valid and useful summary indicator of overall oral health status (1719). Selfrated oral health was represented by the question: in general, how do you consider your oral health? (20) The response options were: very good; good; fair; poor; very poor. The categories very good, good, and fair were collapsed into one group labeled good; the categories poor and very poor were collapsed into a group labeled poor; following the convention established by previous studies (1821). Dichotomized in this manner, good oral health has been shown to be positively correlated with clinical assessments of dental status as well as other measures of perceived oral health functioning and quality of life (18). Pattussi et al. (21) showed that poor self-rated oral health status was signicantly associated with untreated dental caries, missing teeth, dissatisfaction with personal appearance, chewing function, and dental pain in adolescents aged 14 and 15. Cascaes et al. (19) found that the prevalence of poor self-rated oral health was signicantly higher among those who presented with periodontal disease in adults aged 3544.

Materials and methods

Study sample
The setting of our study is Okayama, a mid-sized city in Japan (population 700 000), about one hour west of the city of Osaka by bullet train. The sample of our study consisted of rst-year students enrolled at the Okayama University in 2010. Okayama University had approximately 2300 rst-year students distributed across twelve different departments. Six departments agreed to take part in the survey, representing 1142 students. Of these, 1070 students (mean age SD 18.5 2.5 years) responded to the survey (93.7%). The

Social capital indicators

We inquired about perceptions of social capital in the family, neighborhood, and high school settings (15, 16). Family social capital was assessed by the question: Did you feel your family understood and gave attention to you during high school? (22) Neighborhood social capital was assessed by using

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two questions; Did you feel people trusted each other in your neighborhood during high school (neighborhood trust)? Did you feel that your neighbors stepped in to criticize someones deviant behavior during high school (informal social control)? In the sociological tradition, informal social control refers to the role of community adults in regulating the behavior of members of the group (23). A community that has high levels of informal control is one in which informal agents (e.g., parents and teachers not just agents of the law such as the police) regularly step in to intervene when juveniles in the community are observed to be engaging in deviant behavior, such as underage smoking and drug abuse (24). Japanese society tends to be very tight-knit, and observers have noted that informal control can be almost too strong, thereby creating a sense of oppression and enforced conformity (25). For example, in Japan, deviant behavior has been observed to bring shame (haji) not just to the individuals engaging in deviant behavior (e.g., the adolescent smoker), but also to the groups to which the deviants belong (e.g., their families and schools) (26). School social capital was assessed by three questions; Did you feel teachers and students trusted each other in your high school (vertical school trust)? Did you feel students trusted each other in your high school (horizontal school trust)? Did you feel students collaborated with each another in your high school (reciprocity at school)? The answer options were: strongly agree; agree; neither agree or disagree; disagree; strongly disagree. Then, the disagree and strongly disagree responses were combined to create a dichotomous variable indicating lower group.

variable could be interpreted as either a confounder or a mediating variable. SES was represented by the question: What household income category do you consider yourself to belong to? The self-perceived household income category was dichotomized as: high high-middle middle-middle versus low-middle low. Dental fear was asked through the question: Did you feel anxious when going to the dentist: yes, no?

Statistical analysis
The chi-square test was used to determine if there were any signicant differences (P < 0.05, two sided) between groups. Pearsons correlation coefcient was calculated to examine the correlation among social capital variables. The association between social capital and oral health behaviors was assessed by using the chi-square test. The association of self-rated oral health with social capital indicators was examined in a series of four logistic regression models, and odds ratios (ORs) and 95% condence intervals (CIs) for poor selfrated oral health were calculated. As potential confounders, gender, self-perceived household income category, dental fear, toothbrush frequency, and dental oss use were included in each model. We investigated the association between poor self-rated oral health and family social capital (Model 1), neighborhood social capital (Model 2), and school social capital (Model 3). Finally, we entered all of these social capital variables simultaneously (Model 4) to assess how they inuence oral health mutually. In addition, to explore the independent effects of neighborhood trust and informal social control, the subjects were also divided into four groups as follows: people who reported high trust high informal social control, people who reported low trust high informal social control, people who reported high trust low informal social control, and people who reported low trust low informal social control. The Statistical Package for the Social Sciences (17.0J for Windows; SPSS Japan, Tokyo, Japan) was used for data analyses.

Covariates
Because social capital was hypothesized to inuence oral hygiene practices, we considered oral health behavior as a potential mediator of the association between social capital and oral health (27). As markers of oral hygiene practices, we considered tooth brushing frequency per day and use of dental oss in this study. Socioeconomic status is also associated with both self-rated oral health (18) and social capital (14), and hence we controlled for self-perceived SES as a potential confounder. Dental fear is a predictor of regular visits to the dentist (28). However, it is not clear whether dental fear is associated with social capital. We included it as a control variable in our regression analyses, although its status as a

Results
Overall, 22% of the participants reported having poor oral health. The association between social capital variables and self-rated oral health is illustrated in Table 1. Poor self-rated oral health was signicantly associated with lower levels of

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Furuta et al. Table 1. The characteristics of study subjects, Japan, 2010 (Chi-square test) Poor oral health (n = 208) Family social capital High 189 (20.6) Low 19 (37.3) Neighborhood trust High 159 (19.2) Low 49 (35.3) Informal social control High 162 (21.5) Low 46 (21.5) School trust (vertical) High 168 (19.8) Low 40 (33.6) School trust (horizontal) High 192 (20.9) Low 16 (34.0) Reciprocity at school High 193 (20.9) Low 15 (33.3) Gender Male 144 (21.3) Female 64 (22.1) Self-perceived household income category High Middle 164 (19.2) Low 44 (39.6) Dental fear Without 91 (16.9) With 117 (27.3) Toothbrush frequency More than 3 times 9 (12.7) 2 times 115 (17.9) 1 time or less 84 (33.3) Dental oss use Yes 4 (9.8) No 204 (22.0)

P value 0.005 <0.001 0.995 0.001 0.032 0.048 0.782 <0.001 <0.001 <0.001

0.061

family social capital, neighborhood trust, vertical school trust, horizontal school trust, and reciprocity at school. Poor self-rated oral health was also signicantly associated with self-perceived household income category, dental fear, and toothbrush frequency (Table 1).

The correlation among social capital variables is shown in Table 2. There was a moderate degree of correlation between neighborhood trust and informal social control (Pearsons correlation coefcient = 0.48, P < 0.001). When the association between social capital and oral health behaviors was examined, 43.1% of the subjects with low level of family social capital reported tooth brushing once a day or less frequently, compared to 25.1% of youth with high level of family social capital (P = 0.004). The multivariate logistic regression model included family, neighborhood, and school social capital variables as independent variables (Table 3). Adjusted for gender, self-perceived household income, dental fear, toothbrush frequency, and dental oss use, poor self-rated oral health was signicantly associated with lower level of neighborhood trust (OR 2.22; 95% CI: 1.403.54). Interestingly, poor self-rated oral health was inversely associated with informal social control in the neighborhood (OR 0.54, 95% CI: 0.340.85). When we examined the combined effect of neighborhood trust and informal social control, compared to those who reported high trust high informal social control, low trust high informal social control was signicantly associated with higher odds for poor self-rated oral health (OR 2.17, 95% CI: 1.184.00), whereas a reverse pattern was observed for high trust low informal social control (OR 0.53, 95% CI: 0.300.92). The association was less pronounced for low trust low informal social control (OR 1.21, 95% CI: 0.702.09). Regarding school social capital, poor self-rated oral health was signicantly associated with lower level of vertical trust (OR 1.71; 95% CI: 1.052.80, Table 3), whereas no clear association was found with horizontal school trust or reciprocity at school although the point estimates were in a suggestive direction. In addition, family social capital was not signicantly associated with poor self-rated oral health.

Table 2. Pearsons correlation coefcients of social capital variables Family social capital Family social capital Neighborhood trust Informal social control School trust (vertical) School trust (horizontal) Reciprocity at school All P < 0.001. 1.00 0.30 0.18 0.22 0.20 0.21 Neighborhood trust 1.00 0.48 0.21 0.28 0.23 Informal social control School trust (vertical) School trust (horizontal)

1.00 0.17 0.18 0.17

1.00 0.51 0.36

1.00 0.53

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Social capital and oral health Table 3. The odds ratios for poor self-rated oral health among university students, Japan, 2010 Poor self-rated oral health (n) Family social capital High 189 Low 19 Neighborhood trust High 159 Low 49 Informal social control High 162 Low 46 School trust (vertical) High 168 Low 40 School trust (horizontal) High 192 Low 16 Reciprocity at school High 193 Low 15 Gender Male 144 Female 64 Self-perceived household income category High Middle 164 Low 44 Dental fear Without 91 With 117 Toothbrush frequency More than 3 times 9 2 times 115 1 time or less 84 Dental oss use Yes 4 No 204 OR, odds ratio; CI, condence interval. Model 1 OR (95% CI) 1.00 1.47 (0.782.76) 1.00 2.43 (1.543.84) 1.00 0.57 (0.360.88) 1.00 1.78 (1.102.89) 1.00 1.02 (0.482.19) 1.00 1.40 (0.662.96) 1.00 1.28 (0.901.83) 1.00 2.75 (1.764.27) 1.00 1.84 (1.332.54) 1.00 1.43 (0.683.00) 3.28 (1.527.05) 1.00 2.86 (0.978.40) 1.00 1.23 (0.891.83) 1.00 2.78 (1.774.35) 1.00 1.81 (1.312.51) 1.00 1.45 (0.693.04) 3.41 (1.587.36) 1.00 3.15 (1.069.40) 1.00 1.38 (0.961.99) 1.00 2.63 (1.694.11) 1.00 1.87 (1.352.59) 1.00 1.49 (0.713.14) 3.48 (1.617.53) 1.00 2.98 (1.018.78) Model 2 OR (95% CI) Model 3 OR (95% CI) Model 4 OR (95% CI) 1.00 1.25 (0.662.39) 1.00 2.22 (1.403.54) 1.00 0.54 (0.340.85) 1.00 1.71 (1.052.80) 1.00 1.02 (0.472.22) 1.00 1.34 (0.622.87) 1.00 1.37 (0.951.97) 1.00 2.59 (1.634.10) 1.00 1.83 (1.322.54) 1.00 1.49 (0.713.16) 3.50 (1.617.62) 1.00 3.10 (1.049.23)

Discussion
Understanding of the association between oral health and social environment including social capital could contribute to improving the effectiveness of existing preventive approaches. Therefore, the objective of this study was to investigate the association between self-rated oral health and social capital at family, in the neighborhood, and at school among young people. As a result, young people with lower level of neighborhood trust, higher level of informal social control, and lower level of vertical school trust had poor self-rated oral health. Neighborhood and school social capital might be an important factor inuencing oral health among young people. Previous studies have demonstrated an association between neighborhood social capital and oral health in children and young people (5, 6, 8). For example, in a Japanese study, Aida et al. (8)

showed a protective contextual effect of social cohesion on dental caries. In a Brazilian study, Pattussi et al. found that higher levels of community empowerment were associated with lowered risk of dental injuries (5) as well as dental caries (6). The present study extended the ndings of previous studies by investigating the associations of oral health with social capital indicators assessed among school peers as well as within families. Our study found that neighborhood trust had a protective effect on oral health, whereas informal social control had an adverse effect on oral health. Informal social control refers to the role of adults within a community (not just the childs own parents) in stepping in to prevent the occurrence of deviant health behaviors among youth, such as underage smoking and drug abuse. Previous studies in the US and Europe have suggested that higher levels of informal social control were associated with higher levels of perceived health (29,

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30). Drukker et al. (24) found that higher levels of community informal social control in the Netherlands may directly prevent young people from engaging in deleterious health behaviors as well as indirectly provide them with self-condence and a sense of protection. Our nding of an adverse association between neighborhood informal control and oral health was therefore unexpected, and contradicts previous ndings reported in Europe and the US (29, 30). It suggests that the way in which informal social control operates may vary depending on the cultural context. Culturally, Japanese society is often noted to be a society with very strong levels of social control, especially regarding standards of youth behavior. Japanese people tend to express anxiety about whether or not their behavior is in conformity with informal norms and rules, and they often internalize a strong awareness of how people ought to behave in public (25). These tendencies are expressed by popular aphorisms such as Deru kui wa utareru (the peg that sticks out gets hammered down). Informal social control may be so strong that Japanese youth often feel constrained (25). This may be an instance of the dark side of social capital, i.e., a level of social cohesion that is overly strong resulting in stress and frustration. Because stress impairs oral health through neglect of oral hygiene, changed eating habits, or down-regulation of the host immune response in periodontium (31), an overly high level of informal social control may explain the apparently paradoxical association with worse oral health status. Interestingly, neighborhood trust (a different indicator of social capital) was associated with oral health in a protective direction. When high youth living in trust neighborhoods were stratied by levels of informal social control, we found that those living in high trust high informal control communities reported worse oral health compared to youth living in high trust low informal control communities. Given that neighborhood trust and informal social control were moderately positively correlated (r = 0.48), this pattern suggests that caution is warranted in combining the two indicators to create an overall index of neighborhood social capital. Our data suggest that they may be associated with health in opposite directions. The indicators based in the school social environment suggested that vertical social capital (supportive relations between pupils and teachers) was associated with better oral health, whereas peerbased social capital (horizontal) and norms of

reciprocity were not signicantly associated with oral health. Thus, spending time with peers at school may engender a sense of belonging (32), but it may not promote better oral health. On the other hand, these sense of trust between pupils and teachers may promote oral health by encouraging feelings of safety, acceptance, and support (33). A previous study has described that school connectedness and sense of belonging may have a strong impact on adolescent psychological health (34). Psychological health (e.g., stress resistance resources) has been reported to directly affect oral health in adolescents (35). In addition, stress affects oral hygiene level, health behavior, and inammation in gingiva (31). Thus, the association of school social capital with oral health may reect mediation by the buffering of stress (a psychosocial mechanism) just as much as through behavioral pathways (regular oral hygiene practices). Alternatively, the inuence of school social capital on oral health could be explained by attitudes toward dental visits. In Japan, the oral health examination is implemented on a regular basis according to a school health law. When dental treatment is recommended after an oral health examination, it is the teacher who recommends dental treatment to the student. A trusting relationship between teacher and pupil could increase the uptake of dental treatment. In this study, we did not nd a statistically signicant association between family social capital and self-rated oral health. For young people, family is important for being there in times of need and family members are often regarded as a crucial source of support (32). Morgan and Haglund (36) reported that a sense of belonging in family was related to self-rated health and health behaviors in adolescents. However, studies of preventive health belief and behaviors among youth have also suggested that peers often have a more important direct inuence than parents on subjective health beliefs and health behaviors (37). It is also possible that family social capital did not directly affect oral health in our sample because of the participants age group (18 and 19 years). Our study found a signicant association between family social capital and oral hygiene behavior such as toothbrushing frequency. Brushing frequency was in turn signicantly associated with self-rated oral health. Oral health behavior thus potentially mediates the causal relationship between social capital and oral health status (27). Our study has some limitations. The crosssectional design means that we cannot rule out

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reverse causation, i.e., poor oral health led to low level of trust and other indicators of social capital. Although the survey attempted to preserve temporal ordering by inquiring about current oral health in relation to social capital in high school, we cannot rule out differential recall bias. Moreover, we used a subjective measure of oral health and social capital, and therefore there is a possibility of common method bias. Second, we examined self-perceived household income category as a measure of SES. However, self-perceived household income category is a relatively crude measure of SES and may not reect accurately or fully capture the individuals position in the socioeconomic hierarchy. Third, we did not investigate other psychosocial factors in this study. Psychological distress is related to both oral health (38) and social capital (39), and thus our ndings could reect confounding by omitted third variables (underlying psychological distress). In addition, self-rated oral health is associated with regular dental visits (20), but we did not gather this information in the survey. Fourth, we did not assess the prevalence of specic oral diseases such as dental caries and periodontal disease. Finally, all subjects were recruited among students at Okayama University who had by denition a uniformly high level of education. Our sample may limit the ability to extrapolate our ndings to the Japanese young population. The caution is warranted in generalizing our ndings to the rest of the Japanese population. The present study has demonstrated that higher levels of neighborhood trust and vertical social capital in school (i.e., trusting relationships between pupils and teachers) were associated with better oral health among youth. Higher informal social control in the neighborhood was associated with worse oral health. Neighborhood and school social capital were independently associated with self-rated oral health.

Acknowledgments
We are grateful to Ms. Sayuri Yamada (Okayama University, Okayama, Japan) for helping data entry.

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