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Impact of Social Support on Subjective Oral Health Status among Elderly People

Copyright © The Korean Society of Dental Hygiene Science. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Impact of Social Support on Subjective Oral Health Status among Elderly People Eunsuk Ahn, Jin-Ha Lee, and Sun-Mi Kim Department of Dental Hygiene, Daejeon Institute of Science and Technology, Daejeon 35408, Department of Dental Hygiene, Kyungbok University, Pocheon 11138, Department of Dental Hygiene, Wonkwang Health Science University, Iksan 54538, Korea


Introduction
The health problems of the elderly are indisputably biological and sociological. Health is influenced by the social environment, and health problems result in social problems 1,2) . Health problems associated with aging include the decline of physical function and social and psychological deterioration, which is an economic burden.
Integrated health care is very important for elderly people with chronic diseases 3,4) . Health care is an important positive variable for social support and self-esteem. It is an important factor for maintaining physical and psychological health [5][6][7][8] . Social support refers to a series of actions aimed at satisfying an individual's physical, material, and emotional needs through the individuals' relationships with those around them 9) . Social support, which involves interaction with others, and self-esteem, which has to do with valuing one's self, are components of health care in terms of personal and social integration, and experiences through support in the relationship between the environment and others 2,10) . Social support improves the quality of life and prolongs the life of the elderly and is seen as one of the major factors that affects the health status of the elderly 2,9,11) . Oral health problems among the elderly are a major health problem. Oral health problems result in weakened teeth and high tooth loss rate. Additionally, the oral condition of elderly people is relatively poor than that of individuals in other age groups [12][13][14] . In particular, elderly people with low socioeconomic status experience social disconnection due to social isolation and alienation and the deterioration of their health and quality of life. Dental problems that require treatment seem to diminish one's value and importance 15,16) . Social support and socioeconomic characteristics are considered fundamental determinants of oral health because they can affect proximal risk factors for oral disease, such as developing oral health-related behaviors and modifying lifestyles 17,18) . There is little research on the relationship between oral health and social support in Korea. The purpose of this study was to identify the relationship between oral health and social support in elderly people using representative data. We hope to provide basic data for the development of oral health policies for the elderly who experience social isolation frequently.

Research subjects
This study used Community Health Survey data from the Korea Centers for Disease Control and Prevention.

Research variables
In this study, the subjective oral health status, measured on a 5-point Likert scale, was used as the dependent variable. The higher the social support score, the more positive the perception of social support. Social support items were measured on a 5-point Likert scale. The score was then averaged and used for analysis. As independent variables, social support variables were calculated using the sex, age, household income, education level, Existence of spouse, oral healthcare behavior (regular oral check-up, existence of an unmet dental need), and social support questions (Table 1).

Analysis methods
The general characteristics of the study subjects were investigated using frequency analysis. The t-test and one-way ANOVA were performed to compare the differences in the perceptions of social support according

General characteristics of research subjects
The general characteristics of the study subjects are shown in Table 2

Social support perception according to the general characteristics
The general characteristics and social support perception of subjects are presented in Table 3. The score of the younger elderly was 3.19, which was higher than that of the older elderly (3.10; p＜0.05). Additionally, as household income increased, social support increased significantly (p＜0.05). Moreover, the presence of a spouse significantly affected the perception of social support (p＜0.05).

Factors affecting subjective oral health status
The results of the linear regression analysis to confirm the effect of social support on subjective oral health status are presented in Table 4. Sex, age, household income, education level, presence of a spouse, existence of an unmet dental need, regular oral check-up, and social

Discussion
This is one of the first studies to explore the link between social support and oral health in elderly people nationwide. The data used in this study are representative of the national perspective. The data were obtained from a large population and have undergone representative sampling processes 19) . Among the elderly, the difference in perception of social support according to sex was statistically significant.
According to age, the perception of social support was lower among the older elderly people than among the younger elderly people. This is owing to the decrease in the frequency of contact with children and siblings 20) . In general, the size of social networks and the frequency of social exchanges decrease with age 2,5,8) . This is because physical and mental activities are more limited as one ages. In this study, the higher the household income and education levels, the higher the recognition of social support. The results are consistent with those of previous studies. Elderly people with high socioeconomic status may be more economically active than those with low socioeconomic status. Accordingly, it is thought that social support is highly recognized when people participate more actively in social activities 17,18) . Additionally, the perception of social support among elderly people with spouses was higher. This is consistent with the results of previous studies that reported that elderly people without spouses had weaker social relations than those with spouses 2) . This finding suggests that elderly people without spouses need practical intervention in order to form and maintain supportive friendships. As a result, social support alleviates the stress of older people and provides specific protection and support. In addition, it can be seen that it not only improves immunity to disease, but also maximizes adaptability and resilience, affecting psychological well-being [20][21][22] . The higher the education level of the elderly, the more positive their subjective oral health status. Among the elderly, the level of education adequately reflects changes in past socioeconomic positions and generally affects the subjective oral health status 3,14,18) . These findings are thought to be due to the fact that the lower the economic and educational levels, the greater the risk of oral health problems, and the lower the accessibility to medical information and health care. In addition, elderly people with spouses had higher subjective oral health levels than those without spouses.
This is because elderly people who live alone feel alienated and lonely when they do not receive the support of their family members; hence, their physical, mental, and social health conditions deteriorate 20,21) .
After adjusting for sociodemographic factors (such as sex, age, education level, and household income) and oral health behavioral covariates that are known to affect subjective oral health status, social support was found to be significantly associated with the subjective oral health status 17,18) . This result suggests that social support influences the subjective oral health status of elderly people 1,[21][22][23] . In general, socioeconomic factors and oral health behaviors are considered the main factors that affect oral health 22,24) . Even when these major factors have been adjusted and examined, the effect of social support on subjective oral health was still significant. While poverty has a negative health effect, even among the poor, this negative effect may be alleviated if social support is provided 24) . Therefore, in addition to improving the economic status, efforts should be made to recognize the importance of social support and to provide a formal social support system through community linkage and social welfare programs. In addition, among elderly people, the role of social support can become increasingly important in relation to the additional need of time, resources, and policies for the oral health care of the community system 1,9,23) . During old age, factors that negatively affect social support increase because of the decrease in economic power due to retirement, decrease in physical ability, and death of a spouse. As these factors increase, social support is likely to decrease, which may have a negative impact on health 5,11,22) . Moreover, these factors can have a direct negative effect on health 18,20,21) . Our results emphasize the need for community level action or governmental investment to establish amenities that promote the building of social capital, especially that related on friendship networks. In conclusion, social support is associated with self-reported oral health status among Korean elderly. Obviously, the interdependence of social support and the oral health of elderly people should not be underestimated and should be further investigated.

Conflict of interest
No potential conflict of interest relevant to this article was reported.

Ethical approval
This study was approved by Institutional Review Board of the Daejeon Institute of Science and Technology (IRB-2019-003-017).