Socioeconomic Inequalities In Oral Health Research Articles

Socioeconomic Inequalities in Oral Health among Adults in Guangxi, China.

To examine the relationship between socioeconomic inequalities and oral health among adults in the Guangxi province of China. The present work was designed as a cross-sectional study, and comprises a secondary analysis of the Fourth National Oral Health Survey from 2015-2016. A multistage cluster sampling method was adopted for this survey, conducted in three urban and three rural districts Guangxi province. Dental examinations were conducted to determine oral health indicators: decayed teeth (DT), clinical attachment loss (CAL) and missing teeth (MT). The outcome measures were DT, CAL and MT. A structured questionnaire was used to collect data on demographic characteristics and socioeconomic status (SES). Multiple logistic regression models were used to analyse the relationship between SES and oral health by adjusting covariates. The sample consisted of 651 participants aged 35-74 years. Logisitic analysis showed a statistically significant association between SES and oral health indicators. In the fully adjusted model, participants with primary education were more likely to suffer more DT (OR = 2.67, 95% CI: 1.17-6.10), teeth with CAL ≥ 4 mm (OR = 2.15, 95% CI: 1.25-3.67) and MT (OR = 3.04, 95% CI: 1.65-5.60) compared to the higher education group. Participants with secondary education exhibited a higher likelihood of experiencing increased MT compared to those in the higher education group in the fully adjusted model (OR = 3.21, 95% CI: 1.78-5.76). Household income was associated with DT and MT in the unadjusted model only. There was strong relationship between SES and oral health of adults. The survey suggested a relationship between low educational attainment and oral health.

Socioeconomic Status and Tooth Loss Impact on Oral Health–Related Quality of Life in Chinese Elderly

ObjectiveWe studied the association between the socioeconomic status (SES), tooth loss, and oral health–related quality of life (OHRQoL) in an adult cohort in western China. As socioeconomic inequalities in oral health are often neglected in oral health promotion. we aimed to verify the impact of SES on tooth loss and OHRQoL. MethodsIn all, 348 participants aged 60 years and older were selected for this study. Relationships amongst SES, tooth loss, and OHRQoL were identified by using a structural equation model (SEM). ResultsIn the final sample, 312 people were included, and the response rate was 89.7%. The bias-corrected 95% confidence intervals of the total, direct, and indirect effects were (−0.267 to 0.475), (−0.489 to 0.185), and (0.088 to 0.450), respectively. The comparative fit index of SEM was 0.943. The model showed that their SES directly affected tooth loss in the elderly population. This indirectly affects their oral health–related quality of life. The numbers of natural teeth and occlusal units (with standardised path coefficients of 0.79 and 0.74, respectively) were found to be the most significant factors relating to tooth loss. ConclusionSES affected the oral health–related quality of life in elderly people through tooth loss in a Chinese study population. Our data suggest that improvements in the social and economic environments are a primary measure that should be implmented to prevent tooth loss and improve the OHRQoL.

Social and racial inequity in self-rated oral health in adults in Southern Brazil.

This study aimed to estimate social and racial inequalities in self-rated oral health in adults from the Brazilian birth cohort study. This study belongs to 1982 Pelotas (Brazil) birth cohort study. Data from this study was collected for oral health conditions 31 years old (Oral Health Study). The outcome was self-rated oral health, dichotomized into positive (good/very good) and negative (regular/bad/very bad). Analyses were stratified by gender, racial/skin color groups, schooling level and income. For statistical analysis, the slope index of inequality (SII) and the concentration index (CIX) were used. The prevalence of negative self-rated oral health was 36.1%. Social inequalities were observed in self-rated oral health in both absolute and relative terms. A SII of -30.0 (95%CI: -43.6; -16.4) was observed for income, and -27.7 (95%CI: -41.9; -13.4) for schooling level. Both the individuals' income and the schooling level had negative CIX (CIXincome -14.6 [95%CI: -21.2; -8.0] and CIXschooling level -14.1 [95%CI: -20.7; -7.5]). Furthermore, the prevalence of negative self-rated oral health in black/brown/indigenous individuals from the highest income/schooling level was comparable to prevalence of the outcome in the white individuals belonging to the lowest income/schooling levels. This study results demonstrate racial disparities in oral health regardless of income and schooling levels. Furthermore, a higher concentration of negative self-rated oral health was identified among the most socioeconomically vulnerable individuals. Our findings reinforce the presence of racial and socioeconomic inequalities in oral health.

Greater inequalities in dental caries treatment than in caries experience: a concentration index decomposition approach

BackgroundThe aim of the current study was to (a) measure the socioeconomic inequalities in oral health and examine whether the inequalities are greater in disease experience or in its treatment and to (b) decompose the factors that influence oral health inequalities among the adults of Guangdong Province.MethodsA cross-sectional study was conducted among 35- to 44-year-old and 65- to 74-year-old adults in Guangdong Province. All participants underwent oral health examinations and answered questionnaires about their oral health. We measured the concentration indices of the DMFT and its separate components, namely, decayed teeth (DT), missing teeth (MT), and filled teeth (FT), to explore the inequalities in oral health status; then, we analysed its decomposition to interpret the factors that influence the inequalities.ResultsThe results showed that significant inequality was concentrated on FT (CI = 0.24, 95% CI = 0.14/0.33, SE = 0.05). The concentration indices for the DMFT (CI = 0.02, 95% CI = 0.02/0.06, SE = 0.02) and MT (CI = 0.02, 95% CI 0.03/0.08, SE = 0.03) were small and close to zero, while the concentration for DT (CI = − 0.04, 95% CI = − 0.01/0.02, SE = 0.03) was not statistically significant. The results from the decomposition analysis suggested that a substantial proportion of the inequality was explained by household income, high education level, regular oral examination and type of insurance (5.1%, 12.4%, 43.2%, − 39.6% (Urban Employee Basic Medical Insurance System) and 34.5% (New-Type Rural Medical Collaboration System), respectively).ConclusionsThe results indicated greater inequalities in dental caries than in caries experience. Among the included factors, household income, high education level, and regular oral health examinations had the greatest impact on the inequalities in the number of FT. In addition, the current medical insurance systems, including the Urban Employee Basic Medical Insurance System, Urban Resident Basic Medical Insurance System, and the New-Type Rural Medical Collaboration System, have not been effectively used in oral treatment. Policy-making and the implementation of interventions for tackling socioeconomic oral health inequalities should focus on reducing the burden of treatment and providing greater access to dental care for low-income groups. Welfare policies are skewed towards rural areas and low-income people.

Oral Health of Australian Adults: Distribution and Time Trends of Dental Caries, Periodontal Disease and Tooth Loss.

This study was conducted to describe the distribution and trends in dental caries, periodontal disease and tooth loss in Australian adults based on the findings of the National Study of Adult Oral Health 2017–18. A cross-sectional study of a random sample of Australians aged 15+ years was carried out, employing a three-stage stratified probability sampling design. Data were collected via online survey/telephone interviews using a questionnaire to elicit self-reported information about oral health and related characteristics. Participants were then invited to have an oral examination, conducted by calibrated dental practitioners following a standardised protocol in public dental clinics. A total of 15,731 Australians aged 15+ years were interviewed, of which 5022 dentate participants were orally examined. Results showed that nearly one third of Australian adults had at least one tooth surface with untreated dental caries and, on average, 29.7 decayed, missing or filled tooth surfaces per person. Almost 29% of adults presented with gingivitis while the overall prevalence of periodontitis was 30.1%. Overall, 4% of adults were edentulous while, on average, 4.4 teeth were lost due to pathology. Poorer oral health was evident in Australians from lower socioeconomic backgrounds, indicating socioeconomic inequalities in oral health. Time trends revealed that dental caries experience and tooth retention of Australian adults has improved over 30 years, while periodontal health has deteriorated between 2004–06 and 2017–18. These findings can be used to assist policy makers in planning and implementing future oral healthcare programs.

Dental attendance and behavioural pathways to adult oral health inequalities

BackgroundWhile inequalities in oral health are documented, little is known about the extent to which they are attributable to potentially modifiable factors. We examined the role of behavioural and dental...

Self-reported oral hygiene practices with emphasis on frequency of tooth brushing: A cross-sectional study of Mexican older adults aged 60 years or above.

The objective of the study was to characterize self-reported oral hygiene practices among Mexican older adults aged ≥60 years, and to measure the association between frequency of tooth brushing and a set of sociodemographic, socioeconomic, and dental variables.We conducted a cross-sectional study of 139 older adults aged ≥60 years in Pachuca, Mexico. A questionnaire and a clinical dental examination were administered to identify specific variables. We determined frequency of tooth brushing (or cleaning of dentures or prostheses) and use of toothpaste, mouthwash, and dental floss among respondents. Non-parametric testing was performed for statistical analysis and a multivariate logistic regression model was generated with Stata 11 software to determine frequency of tooth brushing.In our study sample, 53.2% of participants reported brushing their teeth at least once a day, 50.4% always using toothpaste, 16.5% using mouthwash and 3.6% using floss for their oral hygiene. In general, younger and female respondents used oral hygiene aids more than the others. Our multivariate model yielded an association (P < .05) between tooth brushing at least once daily and the following variables: having functional dentition (OR = 12.60), lacking health insurance (OR = 3.72), being retired/pensioned (OR = 4.50), and suffering from a chronic disease (OR = 0.43).The older adults in our sample exhibited deficient oral hygiene behaviors. The results suggest certain socioeconomic inequalities in oral health. The findings of this study should be considered when designing dental care instructions for older adults.

Wider Dental Care Coverage Associated with Lower Oral Health Inequalities: A Comparison Study between Japan and England.

Countries with different oral health care systems may have different levels of oral health related inequalities. We compared the socioeconomic inequalities in oral health among older adults in Japan and England. We used the data for adults aged 65 years or over from Japan (N = 79,707) and England (N = 5115) and estimated absolute inequality (the Slope Index of Inequality, SII) and relative inequality (the Relative Index of Inequality, RII) for edentulism (the condition of having no natural teeth) by educational attainment and income. All analyses were adjusted for sex and age. Overall, 14% of the Japanese subjects and 21% of the English were edentulous. In both Japan and England, lower income and educational attainment were significantly associated with a higher risk of being edentulous. Education-based SII in Japan and England were 9.9% and 26.7%, respectively, and RII were 2.5 and 4.8, respectively. Income-based SII in Japan and England were 9.2% and 14.4%, respectively, and RII were 2.1 and 1.9, respectively. Social inequalities in edentulous individuals exist in both these high-income countries, but Japan, with wider coverage for dental care, had lower levels of inequality than England.

Review of the correlation between social economic status and oral diseases in India

Socioeconomic inequalities in oral health can be defined as the differences in the prevalence or incidence of oral health problems. We assessed the pooled estimate of prevalence of oral diseases among different socioeconomic status (SES) in India by including all articles published up to December 2016 with the prevalence of the oral diseases in SES population using the confined research terms in databases of PubMed and Google Scholar. All articles which had assessed the dental caries, periodontal disease, malocclusion, and oral cancer in different socioeconomic groups were collected. Out of 209 articles retrieved, 19 studies were included. The pooled estimate for mean DMFT for upper, middle, and lower SES status was 3.1 (95% confidence interval [CI] 3–3.1), 2.6 (95% CI 2.6–2.9) and 3.05 (95% CI 3.05–3.04). The prevalence of periodontal disease for (upper SES 12 [95% CI 11–12], middle SES 28 [95% CI 28–29] and lower SES status 60 (95% CI 59–60)] and in (Kuppuswamy scale Upper SES 22 [95% CI 21–22], middle SES 24 (95% CI 23–24] lower SES status 28 [95% CI 27–28]). Our analysis shows that the SES was inversely proportional to the oral diseases. There was a minor variation between DMFT between groups which may be attributed to the lack of large number of studies assessing the SES and dental caries. The pooled estimate of the mean DMFT across the SES status was inconsistent.

Persistent Socioeconomic Inequality in Child Dental Caries in England despite Equal Attendance.

Despite a decline in the prevalence of dental caries among children in England and ongoing arrangements for the provision of free dental care up to the age of 18 y, there is limited information on the pattern and trend of socioeconomic inequalities in dental caries and dental attendance. We estimated the magnitude of deprivation-related inequalities for dental caries and dental attendance in young children, using publicly available data and 2 regression-based summary measures of inequalities: slope index of inequality and relative index of inequality. We found no significant absolute or relative inequalities in dental attendance across English areas in the past decade, while there were persistent absolute and relative inequalities in dental caries. Socioeconomic inequalities in dental caries decreased between 2007 and 2012; thereafter, the relative inequalities increased. The apparent widening inequality in child dental caries in England despite equal access to dental care is a challenge for policy makers. While caries prevalence among English children has declined over the past decade, there has been an increase in socioeconomic inequalities in oral health despite there being no inequality in dental attendance. This has implications for the development of oral health strategy and planning dental services.

Health economics and oral care: an introductory anthology

Healthcare expenditures will continue to increase in the coming years, raising questions regarding the sustainability of the Dutch healthcare system and solidarity, but also about the optimal use of available resources. Given the issues in the oral care sector, attention for economic insights is appropriate there as well. Relevant issues in this regard are the design of the basic and supplementary health insurance schemes for oral care, the market structure and financing of oral care, questions regarding task shifting in oral care, as well as socio-economic inequalities in oral health. A closer cooperative relationship between oral care and the health economy can help in achieving an optimal and sustainable organisation of the Dutch oral care sector. In other words, an organisation contributing in an efficient and fair way to good oral care for all Dutch citizens.

Socioeconomic inequalities in adult oral health across different ethnic groups in England

BackgroundEthnic inequalities in oral health among British adults remain largely unexplored. This study explored the role of socioeconomic position (SEP) in explaining ethnic inequalities in oral health; and the consistency of socioeconomic inequalities in oral health across ethnic groups.MethodsData from 45,599 adults, aged 16 years and over, who participated in the Health Survey for England were pooled across 5 years. The seven ethnic groups included were White British, Irish, Black Caribbean, Indian, Pakistani, Bangladeshi and Chinese. Edentulousness and toothache were the outcome measures. A composite measure of SEP was developed based on education, social class, income and economic activity using confirmatory factor analysis. Ethnic inequalities in oral health were assessed in logistic regression adjusting for sex, age, survey year and SEP.ResultsIndian (OR: 0.55, 95%CI: 0.40–0.76), Pakistani (0.56, 0.38–0.83), Bangladeshi (0.35, 0.23–0.52) and Chinese (0.41, 0.25–0.66) were less likely to be edentulous than White British after controlling for SEP. Irish (1.22, 1.06–1.39) and Caribbean (1.37, 1.19–1.58) were more likely and Bangladeshi (0.83, 0.69–0.99) were less likely to have toothache than White British after controlling for SEP. Socioeconomic inequalities in edentulousness were consistently found across almost all ethnic groups while socioeconomic inequalities in toothache were found among White British and Irish only.ConclusionThis study shows that the role of SEP in explaining ethnic inequalities in oral health depended on the outcome being investigated. Socioeconomic inequalities in oral health among minority ethnic groups did not consistently reflect the patterns found in White British.

Socioeconomic inequalities in oral health in Serbia: evidence from a cross-sectional study

Socioeconomic inequalities in oral health in Serbia: evidence from a cross-sectional study

Socioeconomic Inequalities in Oral Health Among Unmarried and Married Women: Evidence From a Population-Based Study in Japan.

BackgroundSocioeconomic inequalities in oral health have been reported in developed countries, but the influence of marital status has rarely been considered. Our aim was to examine marital status differentials in the association between socioeconomic status (SES) and oral health among community-dwelling Japanese women.MethodsFrom 2010 to 2011, a questionnaire survey was conducted among residents aged 25–50 years in Japanese metropolitan areas. Valid responses were received from 626 unmarried women and 1,620 married women. Women’s own and husbands’ educational attainment and equivalent income were used to assess SES. Self-rated “fair” or “poor” oral health was defined as poor oral health. Multiple logistic regression analysis was conducted to examine which SES indicators were associated with oral health.ResultsThe prevalence of poor oral health was 21.1% among unmarried women and 23.8% among married women. Among unmarried women, equivalent income was not associated with oral health, but women’s own education was significantly associated with oral health; the multivariate-adjusted odds ratio of poor oral health among those with high school education or lower compared to those with university education or higher was 2.14 (95% confidence interval, 1.19–3.87). Among married women, neither women’s own nor husbands’ education was associated with oral health, but equivalent income was significantly associated with oral health, particularly among housewives; the multivariate-adjusted odds ratio of poor oral health among those in the lowest compared with highest income quartile was 1.57 (95% confidence interval, 1.08–2.27).ConclusionsThese findings indicate that marital status should be considered when examining associations between SES and oral health among Japanese women.

Inequalities in oral health among adolescents in Gangneung, South Korea

BackgroundThis study aims to evaluate inequality in oral health among adolescents and to explain the mechanisms of such inequalities in Gangneung, South Korea.MethodsOne thousand two hundred sixty-seven students in their first year from four vocational and three general schools participated in the baseline survey of 2011, and 84.7% of them were surveyed again in 2013. Oral examinations by the same dentist and a self-administered questionnaire were repeated during both waves. Outcome measure for oral health was the existence of untreated dental caries (DT). As socioeconomic position (SEP) indicators, school type (general vs. vocational), father’s and mother’s education, perceived economic status, and Family Affluence Scale (FAS) were measured. Variables measuring oral health related behaviours included tooth brushing frequency, frequency of eating snacks and drinking sodas, smoking, and annual visits to dental clinics. Chi-square tests and panel logistic regression were adopted to examine the associations between dental caries and SEP indicators by STATA version 15.1.ResultsHaving a less educated father and attending a vocational school were significant predictors for untreated caries after controlling for SEP indicators. However, students from general schools, higher SEP by father’s education, perceived economic status, or FAS, or having non-smoking experience or annual visits to dental clinics were more likely to stay caries-free.ConclusionsThere were socioeconomic inequalities in oral health on an adolescent panel. Given that oral health status during adolescents can persist throughout the course of a person’s life, intervention to tackle such inequalities and school environments are required.

Socioeconomic Inequalities in Oral Health among Middle-Aged and Elderly Japanese: NIPPON DATA2010.

BackgroundMost studies on socioeconomic inequalities in oral health have not considered the effects of behavioral and biological factors and age differences. Furthermore, the nationwide status of inequalities remains unclear in Japan.MethodsWe analyzed data from 2,089 residents aged ≥40 years throughout Japan. The lowest quartile of the number of remaining teeth for each 10-year age category was defined as poor oral health. Behavioral and biological factors included smoking status, obesity, diabetes mellitus, high-sensitivity C-reactive protein, and the use of dental devices. Multiple logistic regression analyses were conducted to examine the associations of educational attainment and equivalent household expenditure (EHE) with oral health, and stratified analyses by age category were also conducted (40–64 years and ≥65 years).ResultsLower education and lower EHE were significantly associated with an increased risk of poor oral health after adjusting for age, sex, employment status, marital and living statuses, and EHE/education; the odds ratio for junior high school education compared with ≥college education was 1.84 (95% confidence interval [CI], 1.36–2.49), and the odds ratio of the lowest compared with the highest EHE quartile was 1.91 (95% CI, 1.43–2.56). Further adjustments for behavioral and biological factors attenuated but did not eliminate these associations. EHE was significantly associated with oral health among elderly adults only, with a significant interaction by age category.ConclusionsThose with a lower education and those with lower EHE had a significantly higher risk of poor oral health, even after adjustments for behavioral and biological factors.

Material, behavioural, cultural and psychosocial factors in the explanation of socioeconomic inequalities in oral health.

BackgroundThis study aimed to assess the contribution of material, behavioural, cultural and psychosocial factors in the explanation of socioeconomic inequalities (education and income) in oral health of Dutch adults.MethodsCross-sectional data from participants (25–75 years of age) of the fifth wave of the GLOBE cohort were used (n = 2812). Questionnaires were used to obtain data on material factors (e.g. financial difficulties), behavioural factors (e.g. smoking), cultural factors (e.g. cultural activities) and psychosocial factors (e.g. psychological distress). Oral health outcomes were self-reported number of teeth and self-rated oral health (SROH). Mediation analysis, using multivariable negative binomial regression and logistic regression, was performed.ResultsEducation level and income showed a graded positive relationship with both oral health outcomes. Adding material, behavioural, cultural and psychosocial factors substantially reduced the rate ratio for the number of teeth of the lowest education group from 0.79 (95% confidence interval (CI): 0.75–0.83) to 0.92 (95% CI: 0.87–0.97) and of the lowest income group from 0.80 (95% CI: 0.73–0.88) to 1.04 (95% CI: 0.96–1.14). Inclusion of all factors also substantially reduced the odds ratio for poor SROH of the lowest education group from 1.61 (95% CI: 1.28–2.03) to 1.12 (95% CI: 0.85–1.48) and of the lowest income groups from 3.18 (95% CI: 2.13–4.74) to 1.48 (95% CI: 0.90–2.45).ConclusionIn general, behavioural factors contributed most to the explanation of socioeconomic inequalities in adult oral health, followed by material factors. The contribution of cultural and psychosocial factors was relatively moderate.

Trends in socioeconomic inequalities in oral health among 15-year-old Danish adolescents during 1995-2013: A nationwide, register-based, repeated cross-sectional study.

Scandinavian welfare states, despite having better population oral health than less egalitarian societies, are characterized by ubiquitous social gradients and large relative socioeconomic inequalities in oral health. However, trends in these inequalities among Scandinavian children and adolescents have not been studied in detail. To describe the associations between socioeconomic position (SEP) and oral health in adolescents and to investigate the trends in these associations between 1995 and 2013. Nationwide repeated cross-sectional studies (using individual-level data) were conducted on 15-year-olds in Denmark from 1995, 2003, and 2013 (N=154,750). Dental data were obtained from the national dental register of the Danish Health Authority (Sundhedsstyrelsens Centrale Odontologiske Register [SCOR]) and data on social variables from administrative registers at Statistics Denmark. SEP measures included previous year's parental education (highest attained educational level by either of the parents), income (equivalized household disposable income), and occupational social class (highest recorded occupational class between the parents). Covariates were immigration status, country of origin, number of children and persons in the family, and household type. The outcome was dental caries experience, represented by the decayed, missing, and filled surfaces (DMFS) index. Negative binomial regression models were used to examine the association between DMFS count and each of the explanatory variables separately while accounting for cluster-correlated family data. Furthermore, hierarchical multiple regressions of DMFS on SEP indicators-using the zero-inflated negative binomial (ZINB) distribution as the outcome distribution-were estimated while successively adjusting for the potential effects of the included covariates. Caries prevalence declined from 71% in 1995 to 63% in 2003 and 45% in 2013. Separate assessment of each covariate showed statistically significant graded associations between each covariate and DMFS count at all time points. Similarly, in the ZINB models, in all 3 years, clear gradients were observed in terms of caries differentials in all three SEP categories, with statistically significant associations (Type 3 P values, <.0001) even after adjustment for all other covariates. For instance, in 2013, even among adolescents with positive caries experience, being of lower occupational social class was associated with up to 2.4-fold (95% confidence interval [CI]: 2.2-2.6) higher caries experience. Between 1995 and 2013, relative inequalities increased in all SEP categories, while absolute inequalities decreased in the education and occupation categories. Considerable progress has been made in reducing dental caries rates among Danish adolescents; however, this progress has benefited the disadvantaged social groups less than the better-off groups.

Time-trends in socioeconomic inequalities in oral health among 15-year-old Danish adolescents

Time-trends in socioeconomic inequalities in oral health among 15-year-old Danish adolescents

A cross-sectional survey to assess the effect of socioeconomic status on the oral hygiene habits.

Background:It is widely accepted that there are socioeconomic inequalities in oral health. A socioeconomic gradient is found in a range of clinical and self-reported oral health outcomes.Aim:The present study was conducted to assess the differences in oral hygiene practices among patients from different socioeconomic status (SES) visiting the Outpatient Department of the Sudha Rustagi College of Dental Sciences.Materials and Methods:A cross-sectional survey was conducted from June to October 2014 to assess the effect of SES on the oral hygiene habits. The questionnaire included the questions related to the demographic profile and assessment of the oral hygiene habits of the study population.Results:Toothbrush and toothpaste were being used significantly (P < 0.05) more by lower middle class (84.4%) and upper middle class (100.0%). A significantly higher frequency of cleaning teeth (twice a day) was reported among the lower middle class (17.2%) and upper middle class (21.5%). The majority (34.3%) of the study population changed their toothbrush once in 3 months. The cleaning of tongue was reported by patients belonging to the upper middle (62.0%), lower middle (52.1%), and upper lower class (30.0%). The use of tongue cleaner was reported to be significantly (P < 0.05) more among upper middle (10.1%) class patients. A significantly higher number of patients from the lower class (81.3%) never visited a dentist.Conclusion:The oral hygiene practices of the patients from upper and lower middle class was found to be satisfactory whereas it was poor among patients belonging to lower and upper lower class.