Journal of Public Health Dentistry . ISSN 0022-4006
Prevalence and geographic distribution of edentulism among older Ghanaians Sandra A. Hewlett, BDS, FGCPS1; Benedict N.L. Calys-Tagoe, MD, FWACP2; Alfred E. Yawson, MD, FWACP2; Phyllis Dako-Gyeke, PhD3; Emmanuel Nakua, M.Phil4; Gloria Folson, PhD5; Akosua N. Baddo, MD, FWACP2; George Mensah, MSc2; Nadia Minicuci, PhD6; Paul Kowal, PhD6,7; Richard B. Biritwum, MD, FWACP2 1 2 3 4 5 6 7
Department of Restorative Dentistry, College of Health Sciences, University of Ghana Dental School, Accra, Ghana Department of Community Health, College of Health Sciences, University of Ghana Medical School, Accra, Ghana Department of Social and Behavioral Sciences, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana Department of Community Health, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Nutrition Department, Noguchi Memorial Institute of Research, College of Health Sciences, University of Ghana, Accra, Ghana Multi-Country Studies Unit, World Health Organization, Geneva, Switzerland University of Newcastle Research Centre on Gender, Health and Ageing, Newcastle, New South Wales, Australia
Keywords edentulism; tooth loss; Ghana; older age; aged; WHO; SAGE. Correspondence Miss Sandra A. Hewlett, Department of Restorative Dentistry, College of Health Sciences, University of Ghana Dental School, P. O. Box KB 460, Korle-Bu, Accra, Ghana. Tel: +233 302 680454; Fax: +233 208 112262; e-mail: [email protected]. Benedict N.L. Calys-Tagoe, Alfred E. Yawson, Akosua N. Baddo, George Mensah and Richard B. Biritwum are with the Department of Community Health, College of Health Sciences, University of Ghana Medical School. Phyllis Dako-Gyeke is with the Department of Social and Behavioural Sciences, School of Public Health, College of Health Sciences, University of Ghana. Emmanuel Nakua is with the Department of Community Health, College of Health Sciences, Kwame Nkrumah University of Science and Technology. Gloria Folson is with the Nutrition Department, Noguchi Memorial Institute of Research, College of Health Sciences, University of Ghana. Nadia Minicuci and Paul Kowal are with the Multi-Country Studies Unit, World Health Organization. Paul Kowal is with the University of Newcastle Research Centre on Gender, Health and Ageing, Newcastle, New South Wales, Australia. Disclaimer: The views expressed in this paper are those of the authors. No official endorsement by the WHO or Ministry of Health of Ghana/Ghana Health Service is intended or should be inferred.
Abstract Objectives: Edentulism has important health implications for aging individuals and is used as an indicator of the oral health of a population. Its distribution is unequal within populations, with the greatest burden on disadvantaged and socially marginalized populations. With an increasing older adult population in Ghana, its burden may increase; however, there is no nationwide information on edentulism in Ghana. Focusing on adults 50 years and older, this study assessed the prevalence of edentulism among older Ghanaians and its distribution across the country. Methods: Secondary analysis of WHO’s Study on global AGEing and adult health (SAGE) Wave 1 in Ghana was conducted using self-reported edentulism as the dependent variable. Results: The overall prevalence was 2.8%, varying by sex (men had lower rates; OR = 0.67, 95% CI = 0.47-0.97); by location, being more prevalent in urban areas (3.6%) and the Western Region (4.7%); by education levels (rates were higher among those with no formal education; OR = 1.626, 95% CI = 1.111-2.380); and by marital status (those living without a partner had higher rates; OR = 1.980, 95% CI =1.366-2.870). On multivariate logistic regression, the variables positively associated with edentulism were older age (OR = 0.945) and urban residence (OR = 0.582). Living in the Brong Ahafo (OR = 3.138), Central (OR = 2.172), Eastern (OR = 2.257), or Volta regions (OR = 3.333) was negatively associated with edentulism. Conclusion: Edentulism is unequally distributed across Ghana. Future aged cohorts are likely to follow the same patterns of geographic and social disadvantage if needed interventions are not carried out. This study provides nationwide data to assist service planning.
Received: 1/2/2014; accepted: 8/19/2014. doi: 10.1111/jphd.12075 Journal of Public Health Dentistry 75 (2015) 74–83
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Introduction Complete tooth loss or edentulism is a significant but often overlooked public health problem particularly affecting older adults, despite its declining overall global burden (1). It has been associated with poor socioeconomic status, poor general well-being, and a significant risk of mortality (2). It is known to impair function, including chewing and phonetics, as well as aesthetics, often resulting in limited social and personal interaction and a detrimental effect on quality of life (3). The path to edentulism involves disease-related factors, poor health behaviors, patient preferences, and lack of access to professional dental services. Edentulism rates are often used as an indicator of the oral health of a population and as a reflection of the effectiveness of the preventive and treatment modalities implemented by the health-care delivery system (4). The distribution of oral diseases is unequal between and within countries, with the greatest burden falling on disadvantaged and socially marginalized populations. However, these issues remain relatively underresearched, particularly in low- and middle-income countries. As people age, they remain susceptible to new and repeated episodes of oral disease. The accumulation of lifelong exposures to risk factors and disease eventually lead to tooth loss (3). Tooth loss therefore largely affects older people, who are a growing proportion of the population in Ghana and most countries, with data needed to guide the reconfiguring of social and health services. Ghana is a country located on the western coast of Africa, with an estimated population of 26 million people in 2013. Of this number, 1.5 million are aged 60 years and older. Ghana Dental Association records show that Ghana currently has just 250 practicing dental surgeons: this ratio of 1 dentist per 104,000 population is lower than in most industrialized countries (5). To compound the situation, 75% of these dentists are located in only two administrative regions of the country, the Greater Accra and Ashanti regions. In Ghana and across much of sub-Saharan Africa, a majority of older people live in rural areas where formal health care infrastructure is often rudimentary (6). Furthermore, in countries where population aging is just beginning to be studied, it is unlikely that providers will have accumulated experience or formal training in geriatric services, and the priority of policy-makers may be on other age groups, making the older population disadvantaged (7). The older population in Ghana face conditions that increase vulnerability and potentially add to their disadvantages, including a diminished ability to sustain themselves though pensions, savings or assets; low levels of formal schooling; barriers to health-care access; and the loss or inversion of social roles (8). The prevalence of edentulism has generally been decreasing in many countries due to enhanced availability of oral © 2014 American Association of Public Health Dentistry
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disease prevention and control programs (9) and increased awareness of the importance of oral health. In developing countries, however, edentulism seems to still be increasing (4). This may be because painful teeth are often extracted rather than treated conservatively (9). Furthermore, nondisease factors such as attitude, behaviour, oral health service utilization, characteristics of the health care system, and sociodemographic factors also play an important role in the etiopathogenesis of edentulism. Within countries, regional disparities in edentulism have also been reported, with it being more prevalent among indigenous people, rural and remote dwellers and people of lower socioeconomic status (10). These social determinants of the condition, combined with poor dental care behaviours, require a holistic policy approach to reduce prevalence. Information about the levels and distribution of tooth loss would be a good starting point for planning oral health services, as well as for assessing the effectiveness of preventive and treatment modalities of the health-care delivery system. It may also inform the type and extent of interventions needed in the population. National surveys provide epidemiologic data needed to establish the overall burden of oral disease, develop oral health interventions and monitor changes in oral health indicators, and thus help inform policy. This paper reports on the first nationwide study on aging in Ghana, including oral health data from 4,724 older individuals. It seeks to establish the prevalence and distribution of edentulism, including the regional distributions, among Ghanaians aged 50 years and older.
Methods Study data and design Data for this study were obtained from individuals aged 50 years and older who participated in Wave 1 of the World Health Organization’s (WHO’s) multi-country Study on global AGEing and adult health (SAGE) in Ghana. It was a nationally representative cross-sectional survey carried out from 2008 to 2009 using a stratified, multistage clustersample design. Face-to-face interviews were used to collect data on sociodemographic characteristics, health conditions, health care utilization, tooth loss, and any problems with the respondent’s mouth or teeth. Detailed methods used for the survey, including sampling, interviews, procedures for human subject protection, and consent, have been previously described (11).
Definition of variables Edentulism, which was our dependent variable for this analysis, was assessed with the question “Have you lost all of your 75
Edentulism among older adult Ghanaians
natural teeth?” and all individuals who responded positively or negatively to this question were included in the analysis. The independent variables were selected based on associated factors emphasized in the literature. Four age groups were generated (50-59, 60-69, 70-79 and 80+ years) and used in the analysis. Marital status was categorized into living with partner and not living with partner. Other independent variables included sex, highest educational level completed, urban or rural residence, administrative region, ethnic background, religion, and wealth or income quintile. The United Nations International Standard Classification of Education 1997 (ISCED 97) scheme was used to harmonize education levels to a standard classification scheme. The income quintiles were derived from the household ownership of durable goods, dwelling characteristics, and access to services (improved water, sanitation, and cooking fuel) for a total of 21 assets. Wealth levels were generated through a multi-step process, where asset ownership was converted to an asset ladder and the Bayesian post-estimation method was used to generate raw continuous income estimates that were then transformed into quintiles. Other variables include self-reported diagnosis of diabetes, oral health-care service utilization in the previous 2 weeks and previous 12 months, the health insurance status of the respondents, and self-reported tobacco use based on WHO’s Guidelines for Controlling and Monitoring the Tobacco Epidemic (12). Initially, the question “Have you ever smoked tobacco or used smokeless tobacco?” was asked. Those who responded positively were then asked, “Do you currently use (smoke, sniff or chew) any tobacco products?” The response options “Yes, daily,”“Yes, but not daily,” and “No, not at all” were then recategorized into currently smoking for the first two options and not currently smoking for the last. Utilization of oral health services in the past 12 months and 2 weeks was also assessed for respondents who responded positively to having had problems with their mouth and/or teeth in the past 12 months. All the questions in the questionnaires were translated into and back-translated from all the major local languages in Ghana, following a rigorous translation protocol developed by WHO, with a focus on conceptual equivalence between languages (13).
Statistical analysis Data analysis was carried out using SPSS version 21 statistical software. Statistical significance was set at P < 0.05. Descriptive statistics were used to determine absolute and relative frequencies and distribution of edentulism in the population. To determine the relationship between sociodemographic factors and edentulism, tests of association were conducted 76
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using Pearson’s correlation coefficient. Associations between edentulism and independent factors identified as significantly associated from the bivariate analysis and previous literature were investigated using logistic regression. Odds ratios (OR) and their 95% confidence intervals (CI) from simple and multiple logistic regression models were then used as an assessment of the strength of these factors as predictors of edentulism. Data on stratum sizes and household sizes for selected enumeration areas were obtained and used to calculate weights for individual respondents. Individual weights were generated using selection probabilities at each stage of selection and were poststratified by region, locality, sex, and age groups (18-49, 50-59, 60-69, 70+) according to the 2009 projected population estimates provided by the Ghana statistical service (Figure 1).
Results A total of 27,988 individuals of all ages were observed from 5,266 households; however, only respondents aged 50 years and older (n = 4,724) were included in this study. This age group formed 16.9% of the total household population. The mean age of these 50-plus-year-old respondents was 64.2 years ± 10.7 SD. The sample was quite balanced, with 2,379 (50.4%) men and 2,345 (49.6%) women. Of the 4,724 individuals interviewed, 4,288 individuals responded positively or negatively to having lost all of their natural teeth, making the response rate 90.8%; 436 chose not to respond to the question or had missing data. Of this number, a majority were women (P < 0.001), and the highest frequency of nonresponse (21.8%) occurred in the Upper East Region; otherwise, nonresponders were similar to the respondents included in the analysis. Of the 4,288 individuals who responded to the question, 120 had lost all of their natural teeth, making the overall prevalence of edentulism 2.8%. The mean age of individuals who were edentulous was 70.9 years. Edentulism prevalence varied with age, ranging from 1.5% in the 50-59-year age group to 8.9% in the 80-plus-year age group. Significantly more edentulous respondents were women (P value = 0.034). Analysis by age groups and sex reveals that men tended to be edentulous at an earlier age than women (Table 1). The geographic distribution of edentulism (Table 2) shows variation by region, with the highest prevalence in the Western Region (4.7%) and the lowest prevalence in the Upper West Region (no reported edentulism). Edentulism was more prevalent among respondents not living with partners. Individuals with no formal education had significantly higher rates of edentulism (P = 0.012). For respondents with formal education, however, mean number of years of education did not differ (P = 0.438) between the © 2014 American Association of Public Health Dentistry
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Edentulism among older adult Ghanaians
– –
Prevalence
– –
–
–
–
–
Figure 1 Geographical regional distribution of edentulism among older adults in Ghana.
edentulous (9.2 years) and dentate (8.6 years) groups. Edentulism showed no association with smoking and alcohol use, either currently or in the past. Thirty percent of edentulous respondents had had problems with their mouth or teeth in the past 12 months, compared to 9.5% of the dentate. Of this number, significantly © 2014 American Association of Public Health Dentistry
more edentulous individuals had utilized the services of a dentist (Table 3). In a multivariate logistic regression with edentulism as the dependent variable, increasing age group and urban residence were positively associated with edentulism. Living in the Central, Eastern, Volta, or Brong Ahafo 77
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Table 1 Sociodemographic and Behavioral Factors
Characteristic Sex Women Men Age group 50-59 60-69 70-79 80+ ≥65 Marital status* Living with partner Living without partner Education No formal education Formal education Location of residence Urban Rural Income quintile Q1 (Poorest) Q2 Q3 Q4 Q5 (Richest) Ethnicity Mande–Busanga Mole–Dagbon Akan Ga-Adangbe Grusi Ewe Gruma Guan Religion None Christianity Islam Other Smoking status Ever smoked Never smoked Current smoking status Currently smoking Not currently smoking Alcohol use Ever used Never used Recent alcohol use Yes No Health insurance Insurance No insurance Diabetes Yes No Problems with mouth/teeth Yes No Oral health-care utilization Dental attendance in the past 2 weeks Dental attendance in the past 12 months
Edentulous (N = 120), n (%)
Dentate (N = 4168), n (%)
Prevalence within group (%)
68 (56.7) 52 (43.3)
1,953 (46.9) 2,215 (53.1)
3.4 2.3
26 (21.7) 28 (23.3) 28 (23.3) 38 (31.7) 79 (65.8)
1,656 (39.7) 1,175 (28.2) 950 (22.8) 387 (9.3) 1,888 (45.3)
1.5 2.3 2.9 8.9 4.0
48 (40.3) 71 (59.7)
2,373 (57.2) 1,773 (42.8)
2.0 3.9
77 (64.7) 42 (35.3)
2,196 (53.0) 1,948 (47.0)
3.4 2.1
63 (52.2) 57 (47.5)
1,690 (40.5) 2,478 (59.5)
3.6 2.2
25 (20.8) 23 (19.2) 24 (20.0) 22 (18.3) 26 (21.7)
829 (19.9) 824 (19.8) 831 (20.0) 845 (20.3) 834 (20.0)
2.9 2.7 2.8 2.5 3.0
3 (3.1) 5 (5.1) 71 (72.4) 11 (11.2) 1 (1.0) 4 (4.1) 3 (3.1) 0 (0)
60 (1.9) 101 (3.2) 1,983 (62.5) 426 (13.4) 41 (1.3) 287 (9.0) 211 (6.6) 65 (2.0)
4.8 4.7 3.5 2.5 2.4 1.4 1.4 0
5 (4.2) 86 (71.7) 20 (16.7) 9 (7.5)
211 (5.1) 2,855 (68.7) 658 (15.8) 431 (10.4)
2.3 2.9 2.9 2.1
29 (24.2) 91 (75.8)
1,086 (26.1) 3,080 (73.9)
2.6 2.9
12 (41.4) 17 (58.6)
523 (48.5) 555 (51.5)
2.2 2.9
62 (51.7) 58 (48.3)
2,454 (58.9) 1,714 (41.1)
2.5 3.3
35 (57.4) 26 (42.6)
1,293 (53.1) 1,142 (46.9)
2.6 2.2
47 (39.2) 73 (60.8)
1,595 (38.3) 2,572 (61.7)
2.9 2.8
9 (7.5) 111 (92.5)
158 (3.8) 4,010 (96.2)
5.4 2.7
36 (30.0) 84 (70.0)
396 (9.5) 3,771 (90.5)
8.3 2.2
8 (22.2) 9 (25.0)
21 (5.3) 61 (15.4)
27.6 12.9
negatively
associated
with
edentulism
Discussion
* Living with partner: married or cohabiting; living without partner: widowed, separated, or divorced.
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regions was (Table 4).
Edentulism, which is the complete loss of all natural teeth, is a preventable dental condition and one of the priority oral health indicators proposed by the World Health Organization (14). This study describes the epidemiology of edentulism among older Ghanaians. It is the first comprehensive nationwide study to assess the prevalence and correlates of edentulism in the adult Ghanaian population. As previously observed in the literature, age was significantly associated with edentulism in this study. This may be due to the cumulative effects of dental disease and treatment resulting in increasing tooth loss with age. With Ghanaians living longer, the proportion of older adults and their attendant need for oral health care are increasing. Life expectancy at birth in Ghana increased from 53.8 years in 1980 to 64.7 years in 2013, while the proportion of persons aged 60+ years increased from 4.6% in 1980 to 6.0% in 2013 and is projected to increase to 11.9% by the year 2050 (15). The prevalence of edentulism was 2.8% for the population aged 50 years and above and 4.0% for those aged 65 years and above. This is relatively lower than in most developed countries (16) but is consistent with studies conducted in other African countries (4,17). It is, however, higher than that observed in Ibadan, Nigeria, where Taiwo and Omokhodion (18) reported a prevalence of 1.3% among adults aged 65 years and above. Some authors believe this difference in the pattern of tooth loss may reflect the fact that African populations tend in general to have much less dental caries (19). Thorpe (20), however, argues that levels of edentulism may be artificially low in developing countries due to a shorter life expectancy and thus a much lower percentage of the old and very old. Increasing numbers of people are retaining their natural teeth into old age due to advances in dental care, and the percentage of edentulism has decreased in each age group over the last 20 years in most Western countries; unfortunately, the contrary is the case in less developed countries, where the rate of total edentulism is still increasing (2,4). This may be because painful teeth are often extracted rather than treated conservatively (9). Lack of data, however, makes it difficult to assess trends in Ghana. Eight individuals (0.2%) were aged over 100 years. Of these, no edentulous individual was observed, despite the fact that edentulism was associated with increasing age. This may be because edentulous individuals may be dying at an earlier age relative to their dentate colleagues, corroborating Brown’s assertion that edentulism was associated with allcause mortality (21). © 2014 American Association of Public Health Dentistry
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Table 2 Prevalence by Region Region
n (%)
Men
Women
Rural
Urban
Prevalence
OR (95% CI)
P value
Dentist-topopulation ratio
Ashanti Brong Ahafo Central Eastern Greater Accra Northern Upper East Upper West Volta Western* Total
26 (21.7) 9 (7.5) 12 (10) 15 (12.5) 14 (11.7) 10 (8.3) 2 (1.7) 0 8 (6.7) 24 (20) 120
11 3 4 8 6 5 1 0 2 12 52
15 6 8 7 8 5 1 0 6 12 68
8 3 9 8 2 7 1 0 5 14 57
18 6 3 7 12 3 1 0 3 10 63
3.8 2.2 2.6 2.7 2.9 2.6 0.8 0 1.9 4.7 2.8
1.23 (0.70-2.18) 2.20 (1.009-4.78) 1.81 (0.90-3.67) 1.78 (0.93-3.44) 1.68 (0.86-3.29) 1.85 (0.87-3.91) 6.36 (1.49-27.11) 0 2.48 (1.10-5.59) 1 –
0.468 0.047 0.099 0.084 0.130 0.108 0.012 NA 0.028 0.145 –
1:205,437 1:326,018 1:191,564 1:259,601 1:41,593 1 2,468,557 1:1,031,478 1:677,763 1:1,049,928 1:290,700 1:104,000
* Reference group.
Significantly more edentulous respondents were women, a finding consistent with other studies (22). Contrary to Eklund and Burt (23), however, this study observed that men tended to be edentulous at an earlier age relative to women. The role of sex in edentulism has been suggested to be both social and biological, being related to better dental attendance patterns and dental health behaviour among women, as well as parity, and not just disease occurrence alone. Respondents with no formal education were significantly more likely to be edentulous. This may be a result of improved dental health awareness, increased utilization of oral health facilities, proper oral hygiene habits acquired during the learning process, and peer group influence among the formally educated (4). Data from several countries have consistently shown that edentulism is more prevalent among lower socioeconomic classes (23,24). In this study, however, income and having health insurance showed no association with edentulism. Dental attitudes and perceptions shape oral health-related behaviors (e.g., oral hygiene, dental care use), which in turn shape treatment preferences and receipt of specific dental services. So where tooth loss among the elderly is seen as a part of the aging process and oral diseases are perceived as inevitable natural degenerative processes associated with aging (25), tooth retention may not be a priority, even among those with a high income. In Ghana, wealth may thus not be a significant determinant of tooth loss, but rather education and attitudes and perceptions towards tooth loss may be important. This emphasizes the role of education, and in particular oral health education, in disparities in health. The dental service provider system may also need to undergo a paradigm shift and increase its preventive services rather than focus on the curative. As Ghana’s economy continues to grow, with the country recently attaining lowermiddle-income status, diet and other behaviours may change this relationship between wealth and edentulism in the © 2014 American Association of Public Health Dentistry
country, and these need to be considered as dental services are being planned. Edentulism was more prevalent among individuals living without a partner than among those living with partners. This social construct is motivation to maintain good oral hygiene so as not to offend a partner, thus reducing the risk of tooth loss. This is also partly because in Africa, oral hygiene practices are generally viewed more as a social necessity than as a necessary precaution against dental diseases (25). Furthermore, from a cultural perspective, having never been married and being widowed, divorced, or separated in the Ghanaian setting are potentially stressful and may result in individuals neglecting their oral health. One may also conclude that edentulism affects the subjective well-being of an individual, which affects their relationships. Tsakos et al. (26) observed a similar finding among older US adults, where compared with those who were married or living with a partner, widowed and divorced/separated participants were more likely to be edentulous. Lawton et al. (27) showed a strong association between edentulism and cultural factors linked with particular ethnic groups. In this study, however, no association was found between edentulism and ethnicity. The Mande–Busanga and the Mole–Dagbon tribes recorded the highest prevalence among the ethnic groups. The Mande–Busanga are the smallest ethnic grouping in Ghana, composing about 1.1% of the population of Ghana, and are found largely in the Ashanti Region. Yet the Mole–Dagbon tribe – the second largest ethnic group in Ghana (16.5%), located largely in the northern regions – recorded a high prevalence of edentulism (4.7%) while, overall, individuals living in northern Ghana had a low prevalence of edentulism (2.6%). One may thus deduce that disparities in edentulism prevalence may therefore not be ethnically or culturally related, but rather more based on location of residence. Furthermore, migration and its effects on migrants may play a role in this observation. The 79
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Table 3 Sociodemographic Characteristics and Their Association with Edentulism on Bivariate Logistic Regression Analysis Characteristic Sex Men* Women Age group (years) 50-59 60-69 70-79 80+* Marital status Living without partner* Living with partner Educational status No formal education* Formal education Location of residence Urban* Rural Income quintile Q1 (Poorest) Q2 Q3 Q4 Q5 (Richest)* Religion None Christianity Islam African traditional religion* Ethnicity Akan Ewe Ga–Adangbe Gruma Grusi Guan Mande–Busanga Mole–Dagbon* Smoking status Never smoked* Ever smoked Current smoking status Currently smoking Not currently smoking Alcohol use Ever used* Never used Recent alcohol use Yes* No Diabetes Yes* No Problems with mouth/teeth Yes* No Dental service utilization Dental attendance in the past 2 weeks Yes* No Dental attendance in the past 12 months Yes* No
n (%)
Crude OR (95% CI)
P value
52 (43.3) 68 (56.7)
0.674 (0.468-0.972)
0.034
26 (21.7) 28 (23.3) 28 (23.3) 38 (31.7)
0.160 (0.096-0.261) 0.243 (0.147-0.401) 0.300 (0.182-0.496)
Prevalence and geographic distribution of edentulism among older Ghanaians Sandra A. Hewlett, BDS, FGCPS1; Benedict N.L. Calys-Tagoe, MD, FWACP2; Alfred E. Yawson, MD, FWACP2; Phyllis Dako-Gyeke, PhD3; Emmanuel Nakua, M.Phil4; Gloria Folson, PhD5; Akosua N. Baddo, MD, FWACP2; George Mensah, MSc2; Nadia Minicuci, PhD6; Paul Kowal, PhD6,7; Richard B. Biritwum, MD, FWACP2 1 2 3 4 5 6 7
Department of Restorative Dentistry, College of Health Sciences, University of Ghana Dental School, Accra, Ghana Department of Community Health, College of Health Sciences, University of Ghana Medical School, Accra, Ghana Department of Social and Behavioral Sciences, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana Department of Community Health, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Nutrition Department, Noguchi Memorial Institute of Research, College of Health Sciences, University of Ghana, Accra, Ghana Multi-Country Studies Unit, World Health Organization, Geneva, Switzerland University of Newcastle Research Centre on Gender, Health and Ageing, Newcastle, New South Wales, Australia
Keywords edentulism; tooth loss; Ghana; older age; aged; WHO; SAGE. Correspondence Miss Sandra A. Hewlett, Department of Restorative Dentistry, College of Health Sciences, University of Ghana Dental School, P. O. Box KB 460, Korle-Bu, Accra, Ghana. Tel: +233 302 680454; Fax: +233 208 112262; e-mail: [email protected]. Benedict N.L. Calys-Tagoe, Alfred E. Yawson, Akosua N. Baddo, George Mensah and Richard B. Biritwum are with the Department of Community Health, College of Health Sciences, University of Ghana Medical School. Phyllis Dako-Gyeke is with the Department of Social and Behavioural Sciences, School of Public Health, College of Health Sciences, University of Ghana. Emmanuel Nakua is with the Department of Community Health, College of Health Sciences, Kwame Nkrumah University of Science and Technology. Gloria Folson is with the Nutrition Department, Noguchi Memorial Institute of Research, College of Health Sciences, University of Ghana. Nadia Minicuci and Paul Kowal are with the Multi-Country Studies Unit, World Health Organization. Paul Kowal is with the University of Newcastle Research Centre on Gender, Health and Ageing, Newcastle, New South Wales, Australia. Disclaimer: The views expressed in this paper are those of the authors. No official endorsement by the WHO or Ministry of Health of Ghana/Ghana Health Service is intended or should be inferred.
Abstract Objectives: Edentulism has important health implications for aging individuals and is used as an indicator of the oral health of a population. Its distribution is unequal within populations, with the greatest burden on disadvantaged and socially marginalized populations. With an increasing older adult population in Ghana, its burden may increase; however, there is no nationwide information on edentulism in Ghana. Focusing on adults 50 years and older, this study assessed the prevalence of edentulism among older Ghanaians and its distribution across the country. Methods: Secondary analysis of WHO’s Study on global AGEing and adult health (SAGE) Wave 1 in Ghana was conducted using self-reported edentulism as the dependent variable. Results: The overall prevalence was 2.8%, varying by sex (men had lower rates; OR = 0.67, 95% CI = 0.47-0.97); by location, being more prevalent in urban areas (3.6%) and the Western Region (4.7%); by education levels (rates were higher among those with no formal education; OR = 1.626, 95% CI = 1.111-2.380); and by marital status (those living without a partner had higher rates; OR = 1.980, 95% CI =1.366-2.870). On multivariate logistic regression, the variables positively associated with edentulism were older age (OR = 0.945) and urban residence (OR = 0.582). Living in the Brong Ahafo (OR = 3.138), Central (OR = 2.172), Eastern (OR = 2.257), or Volta regions (OR = 3.333) was negatively associated with edentulism. Conclusion: Edentulism is unequally distributed across Ghana. Future aged cohorts are likely to follow the same patterns of geographic and social disadvantage if needed interventions are not carried out. This study provides nationwide data to assist service planning.
Received: 1/2/2014; accepted: 8/19/2014. doi: 10.1111/jphd.12075 Journal of Public Health Dentistry 75 (2015) 74–83
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© 2014 American Association of Public Health Dentistry
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Introduction Complete tooth loss or edentulism is a significant but often overlooked public health problem particularly affecting older adults, despite its declining overall global burden (1). It has been associated with poor socioeconomic status, poor general well-being, and a significant risk of mortality (2). It is known to impair function, including chewing and phonetics, as well as aesthetics, often resulting in limited social and personal interaction and a detrimental effect on quality of life (3). The path to edentulism involves disease-related factors, poor health behaviors, patient preferences, and lack of access to professional dental services. Edentulism rates are often used as an indicator of the oral health of a population and as a reflection of the effectiveness of the preventive and treatment modalities implemented by the health-care delivery system (4). The distribution of oral diseases is unequal between and within countries, with the greatest burden falling on disadvantaged and socially marginalized populations. However, these issues remain relatively underresearched, particularly in low- and middle-income countries. As people age, they remain susceptible to new and repeated episodes of oral disease. The accumulation of lifelong exposures to risk factors and disease eventually lead to tooth loss (3). Tooth loss therefore largely affects older people, who are a growing proportion of the population in Ghana and most countries, with data needed to guide the reconfiguring of social and health services. Ghana is a country located on the western coast of Africa, with an estimated population of 26 million people in 2013. Of this number, 1.5 million are aged 60 years and older. Ghana Dental Association records show that Ghana currently has just 250 practicing dental surgeons: this ratio of 1 dentist per 104,000 population is lower than in most industrialized countries (5). To compound the situation, 75% of these dentists are located in only two administrative regions of the country, the Greater Accra and Ashanti regions. In Ghana and across much of sub-Saharan Africa, a majority of older people live in rural areas where formal health care infrastructure is often rudimentary (6). Furthermore, in countries where population aging is just beginning to be studied, it is unlikely that providers will have accumulated experience or formal training in geriatric services, and the priority of policy-makers may be on other age groups, making the older population disadvantaged (7). The older population in Ghana face conditions that increase vulnerability and potentially add to their disadvantages, including a diminished ability to sustain themselves though pensions, savings or assets; low levels of formal schooling; barriers to health-care access; and the loss or inversion of social roles (8). The prevalence of edentulism has generally been decreasing in many countries due to enhanced availability of oral © 2014 American Association of Public Health Dentistry
Edentulism among older adult Ghanaians
disease prevention and control programs (9) and increased awareness of the importance of oral health. In developing countries, however, edentulism seems to still be increasing (4). This may be because painful teeth are often extracted rather than treated conservatively (9). Furthermore, nondisease factors such as attitude, behaviour, oral health service utilization, characteristics of the health care system, and sociodemographic factors also play an important role in the etiopathogenesis of edentulism. Within countries, regional disparities in edentulism have also been reported, with it being more prevalent among indigenous people, rural and remote dwellers and people of lower socioeconomic status (10). These social determinants of the condition, combined with poor dental care behaviours, require a holistic policy approach to reduce prevalence. Information about the levels and distribution of tooth loss would be a good starting point for planning oral health services, as well as for assessing the effectiveness of preventive and treatment modalities of the health-care delivery system. It may also inform the type and extent of interventions needed in the population. National surveys provide epidemiologic data needed to establish the overall burden of oral disease, develop oral health interventions and monitor changes in oral health indicators, and thus help inform policy. This paper reports on the first nationwide study on aging in Ghana, including oral health data from 4,724 older individuals. It seeks to establish the prevalence and distribution of edentulism, including the regional distributions, among Ghanaians aged 50 years and older.
Methods Study data and design Data for this study were obtained from individuals aged 50 years and older who participated in Wave 1 of the World Health Organization’s (WHO’s) multi-country Study on global AGEing and adult health (SAGE) in Ghana. It was a nationally representative cross-sectional survey carried out from 2008 to 2009 using a stratified, multistage clustersample design. Face-to-face interviews were used to collect data on sociodemographic characteristics, health conditions, health care utilization, tooth loss, and any problems with the respondent’s mouth or teeth. Detailed methods used for the survey, including sampling, interviews, procedures for human subject protection, and consent, have been previously described (11).
Definition of variables Edentulism, which was our dependent variable for this analysis, was assessed with the question “Have you lost all of your 75
Edentulism among older adult Ghanaians
natural teeth?” and all individuals who responded positively or negatively to this question were included in the analysis. The independent variables were selected based on associated factors emphasized in the literature. Four age groups were generated (50-59, 60-69, 70-79 and 80+ years) and used in the analysis. Marital status was categorized into living with partner and not living with partner. Other independent variables included sex, highest educational level completed, urban or rural residence, administrative region, ethnic background, religion, and wealth or income quintile. The United Nations International Standard Classification of Education 1997 (ISCED 97) scheme was used to harmonize education levels to a standard classification scheme. The income quintiles were derived from the household ownership of durable goods, dwelling characteristics, and access to services (improved water, sanitation, and cooking fuel) for a total of 21 assets. Wealth levels were generated through a multi-step process, where asset ownership was converted to an asset ladder and the Bayesian post-estimation method was used to generate raw continuous income estimates that were then transformed into quintiles. Other variables include self-reported diagnosis of diabetes, oral health-care service utilization in the previous 2 weeks and previous 12 months, the health insurance status of the respondents, and self-reported tobacco use based on WHO’s Guidelines for Controlling and Monitoring the Tobacco Epidemic (12). Initially, the question “Have you ever smoked tobacco or used smokeless tobacco?” was asked. Those who responded positively were then asked, “Do you currently use (smoke, sniff or chew) any tobacco products?” The response options “Yes, daily,”“Yes, but not daily,” and “No, not at all” were then recategorized into currently smoking for the first two options and not currently smoking for the last. Utilization of oral health services in the past 12 months and 2 weeks was also assessed for respondents who responded positively to having had problems with their mouth and/or teeth in the past 12 months. All the questions in the questionnaires were translated into and back-translated from all the major local languages in Ghana, following a rigorous translation protocol developed by WHO, with a focus on conceptual equivalence between languages (13).
Statistical analysis Data analysis was carried out using SPSS version 21 statistical software. Statistical significance was set at P < 0.05. Descriptive statistics were used to determine absolute and relative frequencies and distribution of edentulism in the population. To determine the relationship between sociodemographic factors and edentulism, tests of association were conducted 76
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using Pearson’s correlation coefficient. Associations between edentulism and independent factors identified as significantly associated from the bivariate analysis and previous literature were investigated using logistic regression. Odds ratios (OR) and their 95% confidence intervals (CI) from simple and multiple logistic regression models were then used as an assessment of the strength of these factors as predictors of edentulism. Data on stratum sizes and household sizes for selected enumeration areas were obtained and used to calculate weights for individual respondents. Individual weights were generated using selection probabilities at each stage of selection and were poststratified by region, locality, sex, and age groups (18-49, 50-59, 60-69, 70+) according to the 2009 projected population estimates provided by the Ghana statistical service (Figure 1).
Results A total of 27,988 individuals of all ages were observed from 5,266 households; however, only respondents aged 50 years and older (n = 4,724) were included in this study. This age group formed 16.9% of the total household population. The mean age of these 50-plus-year-old respondents was 64.2 years ± 10.7 SD. The sample was quite balanced, with 2,379 (50.4%) men and 2,345 (49.6%) women. Of the 4,724 individuals interviewed, 4,288 individuals responded positively or negatively to having lost all of their natural teeth, making the response rate 90.8%; 436 chose not to respond to the question or had missing data. Of this number, a majority were women (P < 0.001), and the highest frequency of nonresponse (21.8%) occurred in the Upper East Region; otherwise, nonresponders were similar to the respondents included in the analysis. Of the 4,288 individuals who responded to the question, 120 had lost all of their natural teeth, making the overall prevalence of edentulism 2.8%. The mean age of individuals who were edentulous was 70.9 years. Edentulism prevalence varied with age, ranging from 1.5% in the 50-59-year age group to 8.9% in the 80-plus-year age group. Significantly more edentulous respondents were women (P value = 0.034). Analysis by age groups and sex reveals that men tended to be edentulous at an earlier age than women (Table 1). The geographic distribution of edentulism (Table 2) shows variation by region, with the highest prevalence in the Western Region (4.7%) and the lowest prevalence in the Upper West Region (no reported edentulism). Edentulism was more prevalent among respondents not living with partners. Individuals with no formal education had significantly higher rates of edentulism (P = 0.012). For respondents with formal education, however, mean number of years of education did not differ (P = 0.438) between the © 2014 American Association of Public Health Dentistry
S.A. Hewlett et al.
Edentulism among older adult Ghanaians
– –
Prevalence
– –
–
–
–
–
Figure 1 Geographical regional distribution of edentulism among older adults in Ghana.
edentulous (9.2 years) and dentate (8.6 years) groups. Edentulism showed no association with smoking and alcohol use, either currently or in the past. Thirty percent of edentulous respondents had had problems with their mouth or teeth in the past 12 months, compared to 9.5% of the dentate. Of this number, significantly © 2014 American Association of Public Health Dentistry
more edentulous individuals had utilized the services of a dentist (Table 3). In a multivariate logistic regression with edentulism as the dependent variable, increasing age group and urban residence were positively associated with edentulism. Living in the Central, Eastern, Volta, or Brong Ahafo 77
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S.A. Hewlett et al.
Table 1 Sociodemographic and Behavioral Factors
Characteristic Sex Women Men Age group 50-59 60-69 70-79 80+ ≥65 Marital status* Living with partner Living without partner Education No formal education Formal education Location of residence Urban Rural Income quintile Q1 (Poorest) Q2 Q3 Q4 Q5 (Richest) Ethnicity Mande–Busanga Mole–Dagbon Akan Ga-Adangbe Grusi Ewe Gruma Guan Religion None Christianity Islam Other Smoking status Ever smoked Never smoked Current smoking status Currently smoking Not currently smoking Alcohol use Ever used Never used Recent alcohol use Yes No Health insurance Insurance No insurance Diabetes Yes No Problems with mouth/teeth Yes No Oral health-care utilization Dental attendance in the past 2 weeks Dental attendance in the past 12 months
Edentulous (N = 120), n (%)
Dentate (N = 4168), n (%)
Prevalence within group (%)
68 (56.7) 52 (43.3)
1,953 (46.9) 2,215 (53.1)
3.4 2.3
26 (21.7) 28 (23.3) 28 (23.3) 38 (31.7) 79 (65.8)
1,656 (39.7) 1,175 (28.2) 950 (22.8) 387 (9.3) 1,888 (45.3)
1.5 2.3 2.9 8.9 4.0
48 (40.3) 71 (59.7)
2,373 (57.2) 1,773 (42.8)
2.0 3.9
77 (64.7) 42 (35.3)
2,196 (53.0) 1,948 (47.0)
3.4 2.1
63 (52.2) 57 (47.5)
1,690 (40.5) 2,478 (59.5)
3.6 2.2
25 (20.8) 23 (19.2) 24 (20.0) 22 (18.3) 26 (21.7)
829 (19.9) 824 (19.8) 831 (20.0) 845 (20.3) 834 (20.0)
2.9 2.7 2.8 2.5 3.0
3 (3.1) 5 (5.1) 71 (72.4) 11 (11.2) 1 (1.0) 4 (4.1) 3 (3.1) 0 (0)
60 (1.9) 101 (3.2) 1,983 (62.5) 426 (13.4) 41 (1.3) 287 (9.0) 211 (6.6) 65 (2.0)
4.8 4.7 3.5 2.5 2.4 1.4 1.4 0
5 (4.2) 86 (71.7) 20 (16.7) 9 (7.5)
211 (5.1) 2,855 (68.7) 658 (15.8) 431 (10.4)
2.3 2.9 2.9 2.1
29 (24.2) 91 (75.8)
1,086 (26.1) 3,080 (73.9)
2.6 2.9
12 (41.4) 17 (58.6)
523 (48.5) 555 (51.5)
2.2 2.9
62 (51.7) 58 (48.3)
2,454 (58.9) 1,714 (41.1)
2.5 3.3
35 (57.4) 26 (42.6)
1,293 (53.1) 1,142 (46.9)
2.6 2.2
47 (39.2) 73 (60.8)
1,595 (38.3) 2,572 (61.7)
2.9 2.8
9 (7.5) 111 (92.5)
158 (3.8) 4,010 (96.2)
5.4 2.7
36 (30.0) 84 (70.0)
396 (9.5) 3,771 (90.5)
8.3 2.2
8 (22.2) 9 (25.0)
21 (5.3) 61 (15.4)
27.6 12.9
negatively
associated
with
edentulism
Discussion
* Living with partner: married or cohabiting; living without partner: widowed, separated, or divorced.
78
regions was (Table 4).
Edentulism, which is the complete loss of all natural teeth, is a preventable dental condition and one of the priority oral health indicators proposed by the World Health Organization (14). This study describes the epidemiology of edentulism among older Ghanaians. It is the first comprehensive nationwide study to assess the prevalence and correlates of edentulism in the adult Ghanaian population. As previously observed in the literature, age was significantly associated with edentulism in this study. This may be due to the cumulative effects of dental disease and treatment resulting in increasing tooth loss with age. With Ghanaians living longer, the proportion of older adults and their attendant need for oral health care are increasing. Life expectancy at birth in Ghana increased from 53.8 years in 1980 to 64.7 years in 2013, while the proportion of persons aged 60+ years increased from 4.6% in 1980 to 6.0% in 2013 and is projected to increase to 11.9% by the year 2050 (15). The prevalence of edentulism was 2.8% for the population aged 50 years and above and 4.0% for those aged 65 years and above. This is relatively lower than in most developed countries (16) but is consistent with studies conducted in other African countries (4,17). It is, however, higher than that observed in Ibadan, Nigeria, where Taiwo and Omokhodion (18) reported a prevalence of 1.3% among adults aged 65 years and above. Some authors believe this difference in the pattern of tooth loss may reflect the fact that African populations tend in general to have much less dental caries (19). Thorpe (20), however, argues that levels of edentulism may be artificially low in developing countries due to a shorter life expectancy and thus a much lower percentage of the old and very old. Increasing numbers of people are retaining their natural teeth into old age due to advances in dental care, and the percentage of edentulism has decreased in each age group over the last 20 years in most Western countries; unfortunately, the contrary is the case in less developed countries, where the rate of total edentulism is still increasing (2,4). This may be because painful teeth are often extracted rather than treated conservatively (9). Lack of data, however, makes it difficult to assess trends in Ghana. Eight individuals (0.2%) were aged over 100 years. Of these, no edentulous individual was observed, despite the fact that edentulism was associated with increasing age. This may be because edentulous individuals may be dying at an earlier age relative to their dentate colleagues, corroborating Brown’s assertion that edentulism was associated with allcause mortality (21). © 2014 American Association of Public Health Dentistry
S.A. Hewlett et al.
Edentulism among older adult Ghanaians
Table 2 Prevalence by Region Region
n (%)
Men
Women
Rural
Urban
Prevalence
OR (95% CI)
P value
Dentist-topopulation ratio
Ashanti Brong Ahafo Central Eastern Greater Accra Northern Upper East Upper West Volta Western* Total
26 (21.7) 9 (7.5) 12 (10) 15 (12.5) 14 (11.7) 10 (8.3) 2 (1.7) 0 8 (6.7) 24 (20) 120
11 3 4 8 6 5 1 0 2 12 52
15 6 8 7 8 5 1 0 6 12 68
8 3 9 8 2 7 1 0 5 14 57
18 6 3 7 12 3 1 0 3 10 63
3.8 2.2 2.6 2.7 2.9 2.6 0.8 0 1.9 4.7 2.8
1.23 (0.70-2.18) 2.20 (1.009-4.78) 1.81 (0.90-3.67) 1.78 (0.93-3.44) 1.68 (0.86-3.29) 1.85 (0.87-3.91) 6.36 (1.49-27.11) 0 2.48 (1.10-5.59) 1 –
0.468 0.047 0.099 0.084 0.130 0.108 0.012 NA 0.028 0.145 –
1:205,437 1:326,018 1:191,564 1:259,601 1:41,593 1 2,468,557 1:1,031,478 1:677,763 1:1,049,928 1:290,700 1:104,000
* Reference group.
Significantly more edentulous respondents were women, a finding consistent with other studies (22). Contrary to Eklund and Burt (23), however, this study observed that men tended to be edentulous at an earlier age relative to women. The role of sex in edentulism has been suggested to be both social and biological, being related to better dental attendance patterns and dental health behaviour among women, as well as parity, and not just disease occurrence alone. Respondents with no formal education were significantly more likely to be edentulous. This may be a result of improved dental health awareness, increased utilization of oral health facilities, proper oral hygiene habits acquired during the learning process, and peer group influence among the formally educated (4). Data from several countries have consistently shown that edentulism is more prevalent among lower socioeconomic classes (23,24). In this study, however, income and having health insurance showed no association with edentulism. Dental attitudes and perceptions shape oral health-related behaviors (e.g., oral hygiene, dental care use), which in turn shape treatment preferences and receipt of specific dental services. So where tooth loss among the elderly is seen as a part of the aging process and oral diseases are perceived as inevitable natural degenerative processes associated with aging (25), tooth retention may not be a priority, even among those with a high income. In Ghana, wealth may thus not be a significant determinant of tooth loss, but rather education and attitudes and perceptions towards tooth loss may be important. This emphasizes the role of education, and in particular oral health education, in disparities in health. The dental service provider system may also need to undergo a paradigm shift and increase its preventive services rather than focus on the curative. As Ghana’s economy continues to grow, with the country recently attaining lowermiddle-income status, diet and other behaviours may change this relationship between wealth and edentulism in the © 2014 American Association of Public Health Dentistry
country, and these need to be considered as dental services are being planned. Edentulism was more prevalent among individuals living without a partner than among those living with partners. This social construct is motivation to maintain good oral hygiene so as not to offend a partner, thus reducing the risk of tooth loss. This is also partly because in Africa, oral hygiene practices are generally viewed more as a social necessity than as a necessary precaution against dental diseases (25). Furthermore, from a cultural perspective, having never been married and being widowed, divorced, or separated in the Ghanaian setting are potentially stressful and may result in individuals neglecting their oral health. One may also conclude that edentulism affects the subjective well-being of an individual, which affects their relationships. Tsakos et al. (26) observed a similar finding among older US adults, where compared with those who were married or living with a partner, widowed and divorced/separated participants were more likely to be edentulous. Lawton et al. (27) showed a strong association between edentulism and cultural factors linked with particular ethnic groups. In this study, however, no association was found between edentulism and ethnicity. The Mande–Busanga and the Mole–Dagbon tribes recorded the highest prevalence among the ethnic groups. The Mande–Busanga are the smallest ethnic grouping in Ghana, composing about 1.1% of the population of Ghana, and are found largely in the Ashanti Region. Yet the Mole–Dagbon tribe – the second largest ethnic group in Ghana (16.5%), located largely in the northern regions – recorded a high prevalence of edentulism (4.7%) while, overall, individuals living in northern Ghana had a low prevalence of edentulism (2.6%). One may thus deduce that disparities in edentulism prevalence may therefore not be ethnically or culturally related, but rather more based on location of residence. Furthermore, migration and its effects on migrants may play a role in this observation. The 79
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Table 3 Sociodemographic Characteristics and Their Association with Edentulism on Bivariate Logistic Regression Analysis Characteristic Sex Men* Women Age group (years) 50-59 60-69 70-79 80+* Marital status Living without partner* Living with partner Educational status No formal education* Formal education Location of residence Urban* Rural Income quintile Q1 (Poorest) Q2 Q3 Q4 Q5 (Richest)* Religion None Christianity Islam African traditional religion* Ethnicity Akan Ewe Ga–Adangbe Gruma Grusi Guan Mande–Busanga Mole–Dagbon* Smoking status Never smoked* Ever smoked Current smoking status Currently smoking Not currently smoking Alcohol use Ever used* Never used Recent alcohol use Yes* No Diabetes Yes* No Problems with mouth/teeth Yes* No Dental service utilization Dental attendance in the past 2 weeks Yes* No Dental attendance in the past 12 months Yes* No
n (%)
Crude OR (95% CI)
P value
52 (43.3) 68 (56.7)
0.674 (0.468-0.972)
0.034
26 (21.7) 28 (23.3) 28 (23.3) 38 (31.7)
0.160 (0.096-0.261) 0.243 (0.147-0.401) 0.300 (0.182-0.496)
