Women’s economic empowerment, participation in decision-making and exposure to violence as risk indicators for early childhood caries

Early childhood caries (ECC) is a non-communicable disease with both biological and social constructs. It affects more than 621 million children worldwide [1‐3], and negatively impacts the general health and wellbeing of children [4, 5]. There is extensive literature highlighting the biological etiology and risk indicators for ECC [5‐7] and a few on the family related risk factors. Maternal factors such as age and marital status [8] psychosocial status [9, 10], knowledge of oral health [10, 11] and oral health behavior [12, 13] are risk factors for ECC. The link between maternal health status and child oral health is well-documented [9, 12, 14].

While there is some clarity on the association between maternal wellbeing and ECC, little is known about how social constructs of maternal wellbeing also affects the risk for ECC. One possible social construct that may affect both maternal wellbeing and the risk of a preschooler to ECC is women’s empowerment status, defined as a mother having power and control over resources and decisions [15]. Several publications reported that maternal empowerment is associated with maternal survival [16‐20] and child health outcomes [21, 22]. Empowered mothers are less likely to have malnourished children [23] because they have improved diet quality diversity [24, 25], and support better food consumption [25]. Maternal empowerment is also associated with increased mobility that improves social networking [26, 27], access to health information [16, 28, 29] and access to food and medicines [30, 31].

Women’s empowerment is moderated by maternal education and wealth [16]. Higher maternal education levels and economic status are associated with use of modern health facilities, contraception, preventive care, and reduced smoking [18, 32‐34]. It also improves child health outcomes [24, 35‐44]. Higher maternal economic status is associated with better residential locations that increase access to health services and clean environment [37, 45, 46]; predictors of infant and child morbidity and mortality [45, 47, 48].

Gender inequalities limit access of women to education, job opportunities with significant impact on their economic status [49]. This is also associated with reduced control of resources by women and the risk for abuse [50]. The concept of empowerment was developed as a holistic process to address this inequity. It acts through modifying individual women’s abilities and personal choices and collective growth achieved by cultural norms [51, 52].

We conceptualize that reduced women economic empowerment decreases their decision-making ability, thereby decreasing female agency (i.e, the ability to make things happen) [53, 54]. With decreased agency, the risk of exposure to and tolerance of violence and abuse would increase [55‐57]. This impacts women in ways that reduces the ability of mothers to make health choices for the child [58‐61].

In the absence of accessible evidence on the relationship between women empowerment and ECC we designed this study to determine if there is an association between women’s empowerment, decision-making status, exposure to violence, and the prevalence of ECC. We hypothesized that the higher proportion of empowered women, the lower the prevalence of ECC.

Country-level data on the prevalence of ECC and women economic empowerment, decision-making and exposure to violence reported in the (Appendix A), were used for this ecological study. Figure 1 is a representation of the framework guiding the selection of indicators for this study wherein economic empowerment, decision-making ability and less exposure to violence reflect improved women’s well-being that is associated with lower risk for ECC [62, 63]. The framework was developed based on the Integrated Results and Resources Framework of the United Nations-Women Strategic Plan 2018–2021 [64]. This document included a set of indicators used to measure country progress toward women empowerment. We selected indicators measuring national individual-based performance relative to the total population (percentages) as these were more appropriate to study the micro-level relationship between women’s status and ECC. Indicators related to governments or national guidelines were not used since they imply a macro-level perspective that is beyond the scope of the current study. Mean values for the years 2009 to 2017 were computed.

This is the first study highlighting how women’s empowerment status may be a risk indicator for ECC at a global level. The study findings suggest that the prevalence of ECC for 3 to 5-year-olds was higher where the proportion of women with < 50% of median income was greater and where the proportion of women participating in decisions about socializing was higher. We also observed that the higher the proportion of women who participated in decisions about their own health care, the higher the prevalence of ECC in 0 to 2-year-olds. No associations were identified for women’s exposure to violence and ECC prevalence. Our results, therefore, partly support the study hypothesis.

We avoided the use of a summative index to describe women’s empowerment because this may have obscured item-level distinctions and decrease the predictive value of the construct [24]. The results of our study justified this decision as we noticed that the prevalence of ECC was higher where one indicator of economic empowerment; females living under 50% of median income was worse and where decision-making status was better. Empowerment is a multidimensional concept and its domains are not necessarily correlated [28]. These domains are moderated by different social factors and their pathways for affecting women’s empowerment and ECC may differ.

We found conflicting associations between the prevalence of ECC and indicators of women’s economic empowerment. On one hand, higher prevalence of ECC was observed where there were higher proportion of women with low income suggesting that financial empowerment was associated with less ECC as reported in prior studies [71‐74]. On the other hand, the prevalence of ECC was higher where there were more educated women and food security. We feel this direct relationship between economic empowerment and the prevalence of ECC is because of women’s empowerment is envisioned as their inclusion into paid labor force [75]. Access to maternity leave may enable women to support healthy eating habits and provide oral health care to infants and toddlers [76] thereby reducing their risk for ECC. On return to work, maternal care may diminish if the mother’s attention becomes divided between the child and work [77, 78], negatively affecting dietary and oral hygiene habits, and increasing the risk of ECC especially for older children as the result of this study suggests.

Women’s economic empowerment frameworks that value paid work and undermine the value of domestic care may have a negative impact on child oral health. Economic empowerment policies and programs may need to recognize the needs of women to have fewer hours of work outside home to enable them to care for children, and provide financial support for this home care role. The prior observation that empowerment was associated with less ECC may likely be a result of improved personal hygiene practices rather than conscious decisions about time and money allocation [79]. In addition, lower prevalence of ECC may result with changes in social norms that promote less gendered division of child caretaking responsibilities [80]. Further studies are required to evaluate how maternal economic empowerment impacts pre-school child’s risk for ECC at family, community and country levels.

We also observed that the prevalence of ECC may be higher with two indictors of decision-making. We assume this may be because women with autonomous decision-making powers have greater mobility and better social networking that may result in higher exposure and access of older preschool children to processed cariogenic food [24]. On the other hand, women who are empowered to make decisions about their health may choose to plan pregnancies further apart [16] and increase the duration and frequency of breastfeeding for younger preschool children. Prolonged breastfeeding beyond 24 months of age is a risk factor for ECC in young pre-school children [81, 82]. Nevertheless, this explanation of our study findings needs further exploration.

We postulated that reduced exposure to violence arising from women’s economic and social empowerment may decrease the prevalence of ECC. Violence leads to mental health challenges such as anxiety, depression, and post-traumatic stress disorder [83], which reduce maternal competency to attend to children’s health including oral health [84]. Our findings did not support our postulation and did not agree with the results of few studies demonstrating negative impact of exposure of women to violence on child health [85‐87]. This lack of association reported in our current study may be attributed to the relatively low prevalence of violence practices (exposure to physical/sexual violence and female homicide), which may partly explain the weak and non-significant association.

While our study provided new information on risk indicators for ECC, we call for caution when interpreting the findings because of few limitations. First, we were able to adjust only for country’s economic level. Mutual adjustment for all the factors in the present study was not possible because of data unavailability. Adjusting for one more factor beyond the economic level reduced the sample size in some cases to zero country. We chose to provide an insight into potential relationships between ECC prevalence and indicators of women empowerment using simplified statistical models with minimal adjustment rather than using more comprehensive modeling technique that require data which may not be available in the foreseeable future. Also, macro-level and country-level factors affect the ability of individuals to maintain their and their family members’ health. For example, regardless of the economic empowerment and decision-making ability of a woman, health services can only be accessed and utilized if available. However, we were unable to control for such country-level factors. In addition, we used data from global surveys such as the DHS that generally target non high-income countries (HICs). Because of this, our findings about the association between decision-making ability and ECC prevalence cannot be generalized to HICs. We also had few country-level data on ECC for children 0 to 2 years old, with implications for making findings for this age group not globally representative. ECC is a multifactorial disease and risk factors may differ between cultures with different practices, beliefs and traditions suggesting the need for country-specific studies prior to adoption of our study findings to guide country-level policy formulation and program development. Evidence based on individual-level data collected about the relationship between women empowerment and ECC prevalence in preschool children may support or refute our findings and thus, provide evidence for what our study suggests.

Despite these limitations, our study provided provisional perspective on the complex relationship between women gaining agency through economic empowerment and autonomous decision-making and the risk for ECC. Our study suggests that some measures of women empowerment may be associated with higher risk for ECC and that as women gain “power” they become victims of the pitfalls of modern western society that requires women to do more for economic comfort. This struggle may result in the relegation of homecare duties as mothers may resort to quick meals, packaged meals or sugary snacks. The study findings therefore suggest the need for safeguards for the oral health of children especially in societies with transitional economies that are working towards empowering women. Further studies are required to explore how the gaining of agency by women can reduce the risk for ECC through the institution of supportive policies that do not undermine the economic empowerment of women through mechanisms that positively influence children’s caries risk behavior or through the use of resources (money and time) to acquire healthy food and oral health habits.