Exploring health advice by dental professionals in USA: A secondary data analysis of NHANES (2015-2018).

OBJECTIVES: To examine socioeconomic and ethnic variations in the provision of health advice by dental professionals. METHODS: Data were from the National Health and Examination Survey (NHANES) (2015-2018). Socioeconomic position (Poverty-income ratio and education) and ethnicity were the main exposures. The outcome variable of interest was whether participants received health advice regarding the "benefits of quitting cigarettes," "benefits of monitoring blood sugar levels," and "importance of oral cancer screening". Logistic regression analysis was used to examine the relationship between socioeconomic factors/ethnicity, and health advice after adjusting for covariates. RESULTS: The analysis included a total of 5524 people aged eighteen and above who had complete data. Black and Hispanic individuals had higher odds of receiving advice on smoking (OR = 1.49, 95% CI: 1.04-2.12 and OR = 1.48, 95% CI: 1.05-2.07, respectively) and glucose monitoring (OR = 3.00, 95% CI: 2.03-4.43 and OR = 3.14, 95% CI: 2.04-4.82, respectively), but no significant difference for cancer screening advice.Higher poverty-income ratios (PIR) were associated with lower odds of receiving smoking advice (OR = 0.91, 95% CI: 0.84-0.98), but no significant associations were observed for glucose monitoring or cancer screening advice. The study's findings reveal a social gradient in the provision of cancer advice, with individuals having higher education levels, particularly university education (OR = 1.69, 95% CI: 1.24-2.31), showing significantly higher odds of receiving cancer screening advice CONCLUSION: The study highlights significant variations in health advice provision in dental settings, with education level, ethnicity, and smoking status playing prominent roles, emphasizing the need for targeted interventions to promote equity and cultural competence in delivering health advice in dental settings. PRACTICE IMPLICATION: The results emphasize the importance of strong policies and ongoing education for dental professionals to ensure optimal treatment and prevention.

Inequalities in the Oral Health-Related Quality of Life Among Children in Saudi Arabia.

OBJECTIVE: This study aims to examine the Oral Health-Related Quality of Life (OHRQoL) and its determinants among elementary school children in Saudi Arabia, recognizing OHRQoL as a critical aspect of overall health and well-being. BACKGROUND: OHRQoL is an essential element of health, influencing children's ability to engage in daily activities, learning, and social interactions. In Saudi Arabia, despite free dental care, significant occurrences of untreated dental caries among children highlight disparities in oral health outcomes, likely influenced by socioeconomic factors. METHOD: Baseline data from a longitudinal randomized controlled trial conducted in Riyadh, Saudi Arabia was utilized. Participants were elementary school students attending public schools, selected using stratified cluster random sampling. The study focused on both deciduous and permanent dentition, excluding children with medical issues. Data collection involved clinical evaluations and parental questionnaires, adhering to WHO criteria. RESULTS: The results of the study revealed significant associations between age (mean: 98.99 months, 95% confidence interval (CI): 97.8-100.1) and untreated caries (mean: 2.54, 95% CI: 2.34-2.74) with OHRQoL among children in Saudi Arabia. Older children (Rate Ratio (RR) = 1.01; 95% CI: 1.01-1.06) and those with untreated caries (RR = 1.04; 95% CI: 1.01-1.07) had higher rates of experiencing suboptimal oral health outcomes. However, no statistically significant associations were found for other variables such as gender, family income, parental education, oral hygiene frequency, and dental visits with respect to OHRQoL. CONCLUSION: The study underscores that age and untreated caries are significantly and positively associated with OHRQoL in children. These findings point to the need for targeted oral health interventions and policies within the sociocultural context of Saudi Arabia, particularly focusing on early prevention and addressing socioeconomic inequalities.

Corrigendum: Editorial: Country profile of the epidemiology and clinical management of early childhood caries, volume II.

[This corrects the article DOI: 10.3389/fpubh.2023.1201899.].

Oral Health Workforce in Africa: A Scarce Resource.

The World Health Organization (WHO) African Region (AFR) has 47 countries. The aim of this research was to review the oral health workforce (OHWF) comprising dentists, dental assistants and therapists, and dental prosthetic technicians in the AFR. OHWF data from a survey of all 47 member states were triangulated with the National Health Workforce Accounts and population data. Descriptive analysis of workforce trends and densities per 10,000 population from 2000 to 2019 was performed, and perceived workforce challenges/possible solutions were suggested. Linear regression modelling used the Human Development Index (HDI), years of schooling, dental schools, and levels of urbanization as predictors of dentist density. Despite a growth of 63.6% since 2010, the current workforce density of dentists (per 10,000 population) in the AFR remains very low at 0.44, with marked intra-regional inequity (Seychelles, 4.297; South Sudan 0.003). The stock of dentists just exceeds that of dental assistants/therapists (1:0.91). Workforce density of dentists and the OHWF overall was strongly associated with the HDI and mean years of schooling. The dominant perceived challenge was identified as 'mal-distribution of the workforce (urban/rural)' and 'oral health' being 'considered low priority'. Action to 'strengthen oral health policy' and provide 'incentives to work in underserved areas' were considered important solutions in the region. Whilst utilising workforce skill mix contributes to overall capacity, there is a stark deficit of human resources for oral health in the AFR. There is an urgent need to strengthen policy, health, and education systems to expand the OHWF using innovative workforce models to meet the needs of this region and achieve Universal Health Coverage (UHC).

Socioeconomic and Ethnic Inequalities in the Progress of Multimorbidity and the Role of Health Behaviors.

OBJECTIVES: To assess socioeconomic and ethnic inequalities in the progress of multimorbidity and whether behavioral factors explain these inequalities among older Americans. DESIGN: Health and Retirement Study, a longitudinal survey of older American adults. SETTING AND PARTICIPANTS: Data pooled from 2006 to 2018 (waves 8-14), which include 38,061 participants. METHODS: We used 7 waves of the survey from 2006 to 2018. Socioeconomic factors were indicated by education, total wealth, poverty-income ratio (income), and race/ethnicity. Multimorbidity was indicated by self-reported diagnoses of 5 chronic conditions: diabetes, heart conditions, lung diseases, cancer, and stroke. Behavioral factors were smoking, excessive alcohol consumption, physical activity, and body mass index (BMI). Multilevel mixed effects generalized linear models were constructed to assess socioeconomic and ethnic inequalities in the progress of multimorbidity and the role of behavior. All variables included in the analysis were time-varying except gender, race/ethnicity, and education. RESULTS: African American individuals had higher rates of multimorbidity than White individuals; however, after adjusting for income and education, the association was reversed. There were clear income, wealth, and education gradients in the progress of multimorbidity. After adjusting for behavioral factors, the relationships were attenuated. The rate ratio (RR) of multimorbidity attenuated by 9% among participants with the lowest level of education after accounting for behavior (RR 1.21; 95% CI 1.18-1.23 and 1.11; 95% CI 1.17-1.14) in the models unadjusted and adjusted for behaviors, respectively. Similarly, RR for multimorbidity among those in the lowest wealth quartile attenuated from 1.47 (95% CI 1.44-1.51) and 1.31 (95% CI 1.26-1.36) after accounting for behaviors. CONCLUSION AND IMPLICATIONS: Ethnic inequalities in the progress of multimorbidity were explained by wealth, income, and education. Behavioral factors partially attenuated socioeconomic inequalities in multimorbidity. The findings are useful in identifying the behaviors that should be included in health promotion programs aiming at tackling inequalities in multimorbidity.

Oral health inequality in Canada, the United States and United Kingdom.

The objective of this study was to quantify the magnitude of absolute and relative oral health inequality in countries with similar socio-political environments, but differing oral health care systems such as Canada, the United States (US), and the United Kingdom (UK), in the first decade of the new millennium. Clinical oral health data were obtained from the Canadian Health Measures Survey 2007-2009, the National Health and Nutrition Examination Survey 2007-2008, and the Adult Dental Health Survey 2009, for Canada, the US and UK, respectively. The slope index of inequality (SII) and relative index of inequality (RII) were used to quantify absolute and relative inequality, respectively. There was significant oral health inequality in all three countries. Among dentate individuals, inequality in untreated decay was highest among Americans (SII:28.2; RII:4.7), followed by Canada (SII:21.0; RII:3.09) and lowest in the UK (SII:15.8; RII:1.75). Inequality for filled teeth was negligible in all three countries. For edentulism, inequality was highest in Canada (SII: 30.3; RII: 13.2), followed by the UK (SII: 10.2; RII: 11.5) and lowest in the US (SII: 10.3; and RII: 9.26). Lower oral health inequality in the UK speaks to the more equitable nature of its oral health care system, while a highly privatized dental care environment in Canada and the US may explain the higher inequality in these countries. However, despite an almost equal utilization of restorative dental care, there remained a higher concentration of unmet needs among the poor in all three countries.

Inequalities in the progress of multiple chronic conditions: A systematic review of longitudinal studies.

The objective of this review is to assess the impact of socioeconomic factors on the progress of multiple chronic health conditions (MCC) in Adults. Two independent investigators searched three databases (MEDLINE, EMBASE and LILACS) up to August 2021 to identify longitudinal studies on inequalities in progress of MCC. Grey literature was searched using Open Grey and Google Scholar. Inclusion criteria were retrospective and prospective longitudinal studies; adult population; assessed socioeconomic inequalities in progress of MCC. Quality of included studies and risk of bias were assessed using the Newcastle Ottawa Quality Assessment Scale for longitudinal studies. Nine longitudinal studies reporting socioeconomic inequalities in progress of MCC were included. Two of the studies had poor quality. Studies varied in terms of follow-up time, sample size, included chronic conditions and socioeconomic indicators. Due to high heterogeneity meta-analysis was not possible. The studies showed positive association between lower education (five studies), lower income and wealth (two studies), area deprivation (one study), lower job categories (two studies) and belonging to ethnic minority (two study) and progress of MCC. The review demonstrated socioeconomic inequality in progress of multiple chronic conditions. trial registratiom: The review protocol was registered in the International Prospective Register of Systematic Reviews (CRD42021229564).

Comparing the magnitude of oral health inequality over time in Canada and the United States.

OBJECTIVES: To assess the magnitude of, and changes in, absolute and relative oral health inequality in Canada and the United States, from the 1970s till the first decade of the new millennium. METHODS: Data were obtained from four national surveys; two Canadian (NCNS 1970-1972 and CHMS 2007-2009) and two American (HANES 1971-1974 and NHANES 2007-2008). The slope and relative index of inequality were used to measure absolute and relative inequality, respectively. Percentage change in inequality was also calculated. RESULTS: Relative inequality for untreated decay increased by 91% in Canada and 189% in the United States, while for filled teeth it declined by 63% in Canada and 16% in the United States. Relative inequality in edentulism rose by 200% and 78% in Canada and United States, respectively. Absolute inequality declined in both countries. CONCLUSIONS: There was persistent absolute and relative inequality in Canada and the United States. An increase in relative inequality for adverse outcomes suggests that improvements in oral health were occurring primarily among the rich, while reductions in relative inequality for filled teeth indicate higher utilization of restorative services among the poor. These results point to the necessity of tackling the sociopolitical determinants of health to mitigate oral health inequality in Canada and the United States.

Inequalities in Untreated Root Caries and Affordability of Dental Services among Older American Adults.

The growing geriatric population is facing numerous economic challenges and oral health changes. This study explores the relationship between affordability of dental care and untreated root caries among older American adults, and whether that relationship is independent of ethnicity and socioeconomic factors. Data from 1776 adults (65 years or older) who participated in the National Health and Nutrition Examination Survey (NHANES) were analyzed. The association between affordability of dental care and untreated root caries was assessed using logistic regression models. Findings indicated that untreated root caries occurred in 42.5% of those who could not afford dental care, and 14% of those who could afford dental care. Inability to afford dental care remained a statistically significant predictor of untreated root caries in the fully adjusted regression model (odds ratio 2.79, 95% confidence interval: 1.78, 4.39). Other statistically significant predictors were gender (male), infrequent dental visits, and current smoking. The study concludes that the inability to afford dental care was the strongest predictor of untreated root caries among older Americans. The findings highlight the problems with access to and use of much needed dental services by older adults. Policy reform should facilitate access to oral healthcare by providing an alternative coverage for dental care, or by alleviating the financial barrier imposed on older adults.

The Socioeconomic Inequality in Increment of Caries and Growth among Chinese Children.

BACKGROUND: This study aimed at assessing socioeconomic inequalities in the increment of dental caries and growth among preschool Chinese children, and to assess the best predictor of socioeconomic inequality for each of these conditions. METHODS: This is a longitudinal population-based study. The sample data included preschool children living in three cities of the Liaoning Province, China. At baseline, 15 kindergartens with 1111 participants were included and dropped to 772 with a response rate of 70% at follow-up. Mean ages at baseline and follow-up were 50.82 and 60.55 months, respectively. Median follow-up time was 10.12 months. Data were collected through structured questionnaire, oral examination and anthropometric measurement. The questionnaire collected information on sex, age, family income, mother's education and children's dietary habits. The numbers of decayed, missing and filled teeth (DMFT) was used to indicate dental caries. Weight- and height-for-age z-scores were calculated using the WHO Growth Standard. Multilevel analysis was used to assess the association between baseline socioeconomic position and each of dental caries and child's growth. RESULTS: Mother's education was negatively associated with increments of DMFT. Family income was not significantly associated with DMFT in the fully adjusted model. The association persisted after accounting for other socioeconomic and dietary factors. Higher income was positively related to an increase in the weight-for-age z-score. The relationship between income and changes in the height-for-age z-score was positive and significant in the second highest income group. CONCLUSIONS: Mother's education appeared to be the strongest predictor of increments of dental caries. Only income was significantly associated with an increase in children's weight and height.

Social Inequalities in Use of Preventive Dental and Medical Services among Adults in European Countries.

This study examined inequalities in dental check-ups and medical screenings using subjective and objective socioeconomic indicators. Data from 23,464 adults, aged 20 years old and over, who participated in a multi-national survey across Europe (Eurobarometer 72.3) were analysed. Participants' socioeconomic position (SEP) was measured by education, difficulty in paying bills and subjective social status. Use of preventive services was measured by attendance for dental check-ups, cancer and cardiovascular screenings in the past 12 months. Socioeconomic inequalities were assessed in two-level logistic regression (adults nested within countries), adjusting for demographic factors and type of healthcare system. There were apparent social inequalities in using all three preventive services. However, only dental check-ups showed consistent and significant inequalities across all socioeconomic indicators with those in the bottom groups in education (odds ratio: 0.51; 95% confidence interval: 0.46-0.55), difficulty in paying bills (OR: 0.64; 95% CI: 0.59-0.72) and subjective social status (OR: 0.63; 95% CI: 0.57-0.69) having lower odds of reporting dental check-ups in the past 12 months than those in the top groups. Cancer screening was not associated with difficulty in paying bills whereas cardiovascular disease screening was not associated with education and subjective social status. Despite the availability of universal health coverage, there were clear social gradients in using preventive services particularly across education and subjective social status groups. The stronger and more consistent gradients observed in dental check-ups compared to cancer and cardiovascular screening could be attributed to difference in the level of coverage of dental and medical services in Europe.

Socio-Demographic Variation, Perceived Oral Impairment and Oral Impact on Daily Performance among Children in Saudi Arabia.

Background: This study aimed to describe the oral impact (estimate, severity, frequency) on daily performance (e.g., eating, speaking) and identify the potential perceived oral impairment(s) and socio-behavioral factors associated with oral impact, namely presence or absence of oral impact, among children aged 9-12 years old in Al-Madinah Al-Munawwarah, Saudi Arabia. Methods: A cross-sectional convenience sample of 186 children aged 9-12 years old was recruited. Sociodemographic characteristics, oral health-related behaviors, and perceived oral impairments (e.g., caries, toothache) were obtained from participants. The validated Arabic Child Oral Impact on Daily Performance (C-OIDP) inventory was used to assess oral impacts. Sample descriptive statistics and multivariable logistic regressions modeling the association between C-OIDP and explanatory variables were performed. Results: The mean (±SD) age of the children was 10.29 ± 1.24 years, 66.4% were from public schools, and 52% were females. At least one C-OIDP was reported by 78% of the participants. The mean C-OIDP score was 2.27 ± 1.99. Toothache was reported as a perceived impairment for almost all oral impacts and was the strongest predictor of C-OIDP. Low father income was negatively associated with C-OIDP (odds ratio (OR) = 0.24, 95% confidence interval (CI) = 0.10-0.62). Females had significantly higher odds of reporting C-OIDP than males. Conclusions: In this convenience sample, a high percentage of children aged 9-12 years old reported C-OIDP, which was linked to oral impairment and socio-demographic factors. Further studies, however, are required to explore the clinical, behavioral, and sociodemographic factors in relationship to C-OIDP among Saudi children in a representative sample.

Socioeconomic inequality in the provision of health advice in dental setting in England, Wales and Northern Ireland.

OBJECTIVE: To assess socioeconomic inequalities in health advice provided in dental setting. METHODS: Data were from the Adult Dental Health Survey, 2009 of England, Wales and Northern Ireland. Index of Multiple Deprivation, occupational classification and education were used to assess differences in advice on diet, oral hygiene and dental visits using logistic regression. RESULTS: The analysis included 6279 participants with complete data. There were significant socioeconomic inequalities in all health advice provided in dental setting. Those with a higher level of education had significant odds ratios of 1.36 (1.06-1.75), 1.40 (1.15-1.70), and 1.82 (1.47-2.25) for having advice on diet, dental visits and oral hygiene, respectively compared to those with lower education. CONCLUSION: Inequalities in health advice in the dental setting resemble inequalities in oral health. This implies that those who are most likely to need behaviour-related advice do not receive it. Health policies should address the underpinning causes of inequalities in health advice. PRACTICE IMPLICATIONS: Growing evidence supports the importance of health advice given in dental practice. More time and greater resources should be allocated for comprehensive health advice particularly to the socially disadvantaged to reduce inequalities and subsequently promoting health-related behaviours.

Racial Discrimination and Uptake of Dental Services among American Adults.

This study examined the relationship between racial discrimination and use of dental services among American adults. We used data from the 2014 Behavioral Risk Factor Surveillance System, a health-related telephone cross-sectional survey of a nationally representative sample of adults in the United States. Racial discrimination was indicated by two items, namely perception of discrimination while seeking healthcare within the past 12 months and emotional impact of discrimination within the past 30 days. Their association with dental visits in the past year was tested in logistic regression models adjusting for predisposing (age, gender, race/ethnicity, income, education, smoking status), enabling (health insurance), and need (missing teeth) factors. Approximately 3% of participants reported being discriminated when seeking healthcare in the past year, whereas 5% of participants reported the emotional impact of discrimination in the past month. Participants who experienced emotional impact of discrimination were less likely to have visited the dentist during the past year (Odds Ratios (OR): 0.57; 95% CI 0.44-0.73) than those who reported no emotional impact in a crude model. The association was attenuated but remained significant after adjustments for confounders (OR: 0.76, 95% CI 0.58-0.99). There was no association between healthcare discrimination and last year dental visit in the fully adjusted model. Emotional impact of racial discrimination was an important predictor of use of dental services. The provision of dental health services should be carefully assessed after taking account of racial discrimination and its emotional impacts within the larger context of social inequalities.

Is there socioeconomic inequality in periodontal disease among adults with optimal behaviours.

OBJECTIVE: To examine if socioeconomic inequalities exist in periodontal disease among adult with optimal oral health behaviours. MATERIALS AND METHODS: Data were from the Adult Dental Health Survey 2009, a national survey of England, Wales and Northern Ireland. Overall, 4738 participants aged 35 years and older were included in the analysis. Periodontal disease indicated by pocket depth or loss of attachment ≥4 mm, and gingival bleeding were used as periodontal outcomes. Education and deprivation indicated socioeconomic position. Behavioural factors were dental visits, toothbrushing and smoking. The subset of adults with and without optimal health related behaviours included 2916 and 1822 participants, respectively. The associations between periodontal disease and socioeconomic position were tested adjusting for demographic and behavioural factors. Additional models stratifying the sample to those with and without optimal behaviour subgroup were constructed. RESULTS: Education and deprivation were significantly associated with periodontal disease in the partially adjusted models. In the analysis of those with optimal behaviours, only deprivation and highest level of education showed significant association with periodontitis (PD), but not with gingival bleeding. Among those without optimal behaviours, all socioeconomic factors were associated with all outcomes except deprivation and PD. CONCLUSIONS: Oral health behaviours marginally contributed to inequalities in gingival bleeding and periodontal disease. Socioeconomic inequalities were attenuated among those with optimal behaviours and persisted among those without optimal behaviours. Behaviours appeared to be an effect modifier for the relationship between periodontal outcomes and socioeconomic factors.

Do Socioeconomic Conditions Explain Ethnic Inequalities in Tooth Loss among US Adults?

Objective: To assess whether there are ethnic differences in tooth loss among adult Americans aged <40 years and whether socioeconomic position attenuates these differences if they exist. Methods: Data were from the 2014 Behavioral Risk Factor Surveillance System, a health-related telephone cross-sectional survey of a nationally representative sample of US adults. Tooth loss (one tooth or more) was used as the outcome variable. Ethnicity was the main explanatory variable. Family income, education and health insurance were also used in the analysis. Logistic regression models for tooth loss were constructed adjusting for demographic (age, sex, and ethnicity), socioeconomic indicators (income and education), health insurance, dental visits, smoking and diabetes. Results: A total of 76,273 participants were included in the analysis. The prevalence of tooth loss was highest among Blacks (33.7%). Hispanics and other ethnic groups had a higher prevalence of tooth loss than Whites, 29.1% (95%CI: 27.7-30.6), 22.0% (95%CI: 20.3-23.8), and 20.8% (95%CI: 20.2-21.4), respectively. Blacks had odds ratios (OR) 1.98 (95%CI: 1.81-2.16) for tooth loss compared with Whites. After adjusting for socioeconomic positions (SEP), the relationship attenuated but remained significant with OR 1.71 (95%CI: 1.55-1.90). Conclusions: Despite recent changes in the health care system in the United States, ethnic inequalities in tooth loss still exist. Income and education partially explained ethnic differences in tooth loss among Americans aged <40 years.

The role of healthcare and education systems in co-occurrence of health risk behaviours in 27 European countries.

Background: Contextual factors play an important role in health and related behaviours. This study aims to examine the association of co-occurrence of five health-risk behaviours with healthcare and education contextual factors using nationally representative samples from 27 European countries. Methods: Data were from Eurobarometer 72.3, 2009. The outcome was a count variable ranging from 0 to 5 indicating co-occurrence of five health-risk behaviours, namely smoking, excessive alcohol consumption, non-frequent fresh fruit consumption, physical inactivity and non-dental check-ups. Public expenditures on healthcare and education as a percentage of GDP and quality of healthcare and education at a country-level were used as contextual factors. A set of multilevel Poisson regression models were conducted to examine the associations between co-occurrence of health-risk behaviours and each of the contextual factors considering age, gender, marital status, urbanisation, individual socioeconomic positions (education, subjective social status or difficulty in paying bills) and GDP per capita. Results: The total population was 23 842. Greater expenditures on healthcare and education, and better quality of healthcare systems had negative associations with co-occurrence of health-risk behaviours in the model adjusted for all individual demographic indicators. However, statistical significance disappeared after adjusting for socioeconomic indicators and GDP per capita. Conclusion: While the study highlights the importance of developing high-quality healthcare and education systems generously supported by public fund in relation to co-occurrence of health-risk behaviours, the influence of contextual factors in adopting health-related behaviours is probably attenuated by individual socioeconomic factors.

Socioeconomic inequality in clusters of health-related behaviours in Europe: latent class analysis of a cross-sectional European survey.

BACKGROUND: Modifiable health-related behaviours tend to cluster among most vulnerable sectors of the population, particularly those at the bottom of the social hierarchy. This study aimed to identify the clusters of health-related behaviours in 27 European countries and to examine the socioeconomic inequalities in these clusters. METHODS: Data were from Eurobarometer 72.3-2009, a cross-sectional survey of 27 European countries. The analyses were conducted in 2016. The main sections of the survey included questions pertaining to sociodemographic factors, health-related behaviours, and use of services. In this study, those aged 18 years and older were included. We selected five health-related behaviours, namely smoking, excessive alcohol consumption, frequent fresh fruit consumption, physical activity and dental check-ups. Socioeconomic position was indicated by education, subjective social status and difficulty in paying bills. Latent class analysis was conducted to explore the clusters of these five behaviours. Multinomial logistic regression model was used to examine the relationships between the clusters and socioeconomic positions adjusting for age, gender, marital status and urbanisation. RESULTS: The eligible total population was 23,842. Latent class analysis identified three clusters; healthy, moderate and risky clusters in this European population. Individuals with the lowest socioeconomic position were more likely to have risky and moderate clusters than healthy cluster compared to those with the highest socioeconomic position. CONCLUSIONS: There were clear socioeconomic gradients in clusters of health-related behaviours. The findings highlight the importance of adopting interventions that address multiple health risk behaviours and policies that tackle the social determinants of health-related behaviours.