This was the first study attempting to study the association between IPV and ECC using national data available from multiple countries around the world. This data suggest that in countries with higher proportion of women facing physical, sexual and emotional IPV, the prevalence of ECC is also higher. This relationship was not statistically significant likely due to the relatively few number of countries with available information from the Demographic Health Survey. In addition, the effect size observed is small though this not unexpected in view of the multifactorial nature of ECC and because IPV may be partly explained by the other major social determinant of health like education and income (for which we controlled in our analysis). The study finding however highlights an area for future research as there are indications that the global incidence of IPV has been on the increase [45]. The pathway for this association also needs to be further studied. This includes studying the possible link between IPV and culture, association between IPV and the presence/absence of national laws that protect women and their rights.
The study provides new information to strengthen existing evidence on how social context is associated with disease risks. Globally, the prevalence of ECC is high – it is the 10th most prevalent childhood illness [46]. Most of the efforts to address this problem have largely been limited to interventions aiming at altering biological and behavioral risk factors. Little attention has been paid to addressing the social determinants of health, which can impact the behavioral and biological risks.
Highlighting how IPV impacts negatively on the oral health of pre-school children has two implications: the percentage of children with ECC in LMICs may be associated with care-givers’ risk of exposure to IPV. Identification of caregivers experiencing IPV may help with identifying child at risk for ECC at a young age. The first implication also reiterates the importance of integrated maternal and child health care as a cost-effective mechanism to manage diseases using the common risk approach [47]. There is currently very little evidence on approaches that promote the integration of maternal and child general healthcare with their – and especially the child’s- oral health. As evidence emerges, it will be important to develop programs addressing maternal IPV and ECC in pre-school children as part of a general health screening process, especially in countries where the prevalence of IPV is high.
The second implication of the finding from this study is the challenge with planning macro-level interventions and using micro-level measures to assess success. Pending further confirmation from future studies, the association between IPV and ECC shown in this study may indicate the possibility of using ECC prevalence to monitor the success of country-level programs addressing IPV. However, there are very few countries that conduct regular national oral health surveys; and fewer that collect oral health data in pre-school children. Our findings highlight the importance of national ECC surveys so that this data can be used as an indirect, although may be less sensitive measure, of the impact of interventions to control IPV. Existing studies and reviews of the IPV and oral health literature reveal that the link between IPV and ECC is quite plausible [48]. Integrating early childhood promotion and ECC prevention messaging into women’s shelters may be a first step to reduce the risk for caries and offer women practical methods to care for their children’s oral health.
One of the strengths of the present study is the use of population-level data derived from the Demographic Health Survey thus ensuring data quality [49]. We used the data from 20 LMICs to provide insight to a phenomenon that if further explored, may shape policy and practice around ECC management [50]. Our study is however limited by the low number of included countries thereby challenging the generalizability of findings. The low sample size was addressed by using partial eta squared, a measure of effect size, to compare the association of ECC with various forms of IPV and to decide on the importance of each variable, rather than using the p values to determine the significance of the associations. Ensuring the availability of IPV data in other countries with different income levels may help develop a better understanding of the nature of the association between ECC and IPV.
Another limitation is that IPV data is based on self-reporting with the possibility of under-reporting due to social desirability bias [51]. However, this is the standard method used to obtain IPV statistics [52]. In addition, the study is ecological with potential for ecological fallacies [53, 54]; and its cross-sectional design has limited use in establishing a cause-effect relationship between ECC and IPV. We also only extracted data on IPV and women though there are evidence suggestive that both males and females may be victims of IPV [55, 56]; and IPV affecting men may be associated with the risk of ECC [26].