Social vulnerability experienced by collectors of recyclable materials has a strong influence on their understanding and confrontations health. This research aimed to explore the relationship between oral health and perception of subjects in a context of social disadvantage, in order to support concrete alternatives for action on (oral) health conference. This was a qualitative study carried out with representatives of an autonomous community of Brazilian collectors of recyclable materials. Data were collected through interviews and focus group treated with the technique of qualitative analysis. Respondents showed perceptions of etiology and care practices on oral health promoted beliefs and values collectively instituted in a social risk territory. Also, they associate the quality of their oral health and their difficulty of public access to the context of social vulnerability. This study suggests the adoption of protective, educational and interceptive in oral health practice in order to improve and enable the oral health status of this population.
The recyclable materials accumulation, added to the unemployment, informality and precariousness of labor relations, low access to information, services and the limited availability of resources [
Studies show the poor living conditions, work and structural factors of this group of workers as important potentiating agents of human vulnerability [
Particularly to the field of public health, it is assumed that exposure to adverse situations is distributed unevenly individuals according regions and social groups [
Based on these, and also the lack of studies in the literature that consider the perceptions of collectors of recyclable materials, it was sought in this study to explore the relationship between oral health and perception of sub- jects in a context of social risk, in order to support alternative concrete intervention in health (oral) conference.
This cross-sectional observational study, exploratory and qualitative approach was performed on an autonomous community of recyclable materials in a city of southern of Brazil, in 2013. The sample was chosen through the unique status of weakness exposed by the subjects, taking into account its historicity and its responsiveness around the vulnerabilities related to the theme and its aftermath.
The study was formed by 31 families and approximately 180 individuals living in an area of invasion, considered in social risk, this society is marked by highly social and economic precarious indicators, such as lack of water supply and sewage, unregulated electricity, plenty of garbage, risks of various kinds, among others. In the list of your daily, adults and children assignments are meant to collect, select and sell solid recyclable materials such as paper, cardboard and glass, as well as ferrous and non-ferrous materials and other reusable materials.
The study population was formed by the totality of informal representatives, but declared legitimate and popularly of that community (n = 6), all women with incomplete primary education aged by 26 to 57 years. The number of subjects was defined initially considering the possibility of recruiting other reporters. However, during the study, the amount proved to be sufficient, since the empirical data obtained allowed to draw a comprehensive picture of the issue under investigation. Although the qualitative methodology work with a small sample of subjects, authors have shown that in one speech is contained the whole representation of certain groups in historical, socioeconomic and cultural specific conditions enabling a trustworthy manner deepen the complexity of the phenomenon under study [
The elements of interest for the study were seized by the technique of focus group interviews [
This step was conducted in a one meeting, by a single researcher who explained about the functioning of the group, voluntariness, confidentiality and non-identification of participants, and requested consent to record. Lasting about 50 minutes, it was used the saturation criterion for closing [
At the end of the interview, subjects were instrumented on educational and preventive aspects of oral health through dialogue with researchers and the acquisition of a printed information sheet.
The speeches were transcribed and analyzed qualitatively using the technique of qualitative analysis [
In the pre-analysis step, the material was organized into three thematic categories and a superficial reading of the same was held aiming at a comprehensive apprehension of meaning. Subsequently, further exploration of this material was made with thorough reading of the speeches, extracting words or phrases that answered the guiding questions, so-called core meanings in order to subcategorize them [
All subjects were informed about the purpose of the research, their character and willingness of non-identifica- tion, as well as how to collect, analyze and target data. Those who agreed to participate did so through the sign- ing of a free and informed consent. The study was approved by the Ethics Committee on Research Involving Humans of the Ponta Grossa State University (COEP-UEPG Opinion No. 226.155/2013), respecting the dictates of Resolution 466/12 of the National Health Council (Brazil), and the Declaration of Helsinki.
The community of recyclable material collectors was composed mostly of young adults with low education and less than one Brazilian minimum wage (US $308.00) monthly income. The households were composed of married couple and 3 - 4 children, or couples with young children and grandchildren. Residences occupied areas unsuitable, were built of wood and plastic sheeting, composed of two or three rooms. The water access was from contaminated streams and the electricity was irregular.
Self-perceived oral health, interpretation of the experience of health and its condition in the context of daily life [
The precarious living conditions of the collectors in this study revealed an unexpected and insightful influence on their perception of health, noting that oral diseases are not a condition accepted. This result endorses the so-called critical geopolitical populations attribute, which is the understanding that every perception, value and observed practice should be analyzed both in the context of social inequality and space as in power structures [
“Oh, I think my mouth health is bad. I thought I’m poor and collectors of recyclable materials, my mouth doesn’t need to be like this.”
“... Mine neither, there are many ugly things. Everyone deserves good tooth, right?”
Although the health assessment by lay people in general, show disparity with the clinical condition found [
“There is a tooth here that needs treatment, I know it’s just like my husband’s. But for us, who are poor and lives with garbage is really complicated have beautiful teeth. I think it really influences, it’s difficult.”
“(...) When it leaves those hard wounds in my mouth, I know I have to look for the dentist, I leave the service only if have no way, because the money of the day fouls.”
“(...) It seems that we’re with a brick in our mouth, the tooth gets high... so, we need to go to the dentist. I think it might be messing with such dirty thing... but I never go to the dentist.”
Problems associated with oral health have been increasingly recognized as important causes of negative impacts on daily performance and quality of life of individuals and society [
The collectors of recyclable materials clearly exposed the association between missing teeth, their social status and barriers in everyday life:
-At work:
“I think it (missing teeth) interferes with work, because if you don’t have good teeth, you can not get good service (...). But with so many things that we need, where is the money to pay the dentist?”
“That (missing teeth) counts a lot, if you want a fix servisse, you have to take care of your appearance, especially of your teeth. With this work we can’t take care (...).”
“... They think if they don’t take care of that appearance as well, you can’t take care of the office they will give you... else who is poor and lives of garbage has no chance”.
“And the worst is that the same thing happens with our children... well, we wanted, but we can’t take good care of their teeth... so without good teeth, our children who were created here in the trash can’t arrange a better job and end up working for right here, and we didn’t want it for them.”
-In communication skills and social contacts:
“When I see a party I close the face, when I felt my teeth were better, I took the pictures, giggled... felt better, despite the poverty. Then I looked in the mirror and saw that wasn’t good, I started to take pictures with my mouth closed, people look and say I was with the bad guy, brave face. But what will I do? Hide the teeth.”
“We will talk and already give up, huh? We ourselves feel that we have bad breath in the mouth... Also, working with the garbage all day I think the smell gets on us.”
-Masticatory function:
“It’s hard to eat without the teeth, right? We’ll eat anything hard and we can’t. And here we eat everything, no luxury.”
“We want to eat an apple and we can’t because is expensive, but when we purchase, we have to eat kust like a child, shaving with spoon.”
The relationship between pain variable or oral discomfort and impact on daily activities was not directly mentioned by the respondents of this survey, despite showing is closely associated with teeth loss and exposure to physical and social risks:
“I took them all (teeth) because my entire pregnancy I suffered with toothache and now I’m out of sheets... most here do it to avoid the risk of suffering pain and the risk of having no way to pay the dentist.”
“I also pulled everything (teeth) because toothache makes me want... I don’t know what, right? I have no condition to be fixing my tooth and buying expensive thing to wear in the mouth.”
Considering the broad conceptual provisions relating to the health-disease process, which determine which individuals or populations, throughout its existence, will experience health and disease based on their potential, their living conditions and their interaction with them [
With regard to the aspects related to the lack of maintenance of teeth, most respondents believe that they are guided mainly on individual responsibility, self-care, habits adopted lifelong and precariousness of their living conditions. This result corroborates previous studies [
“... I think my tooth has spoiled because of coffee and cigarette, because I smoke and drink coffee enough... I learned to smoke early, is common smoking here.”
“... My girl has enough spoiled tooth, because she eats a lot of candy and she doesn’t brush the tooth properly. I advice to toothbrush, but I don’t have enough time to take care if she brushed the tooth or not... and I can’t buy a new toothbrush all the time. I work all day long, the end of the day I just want relax.”
Still, for the subjects of the present study and in agreement with findings of other studies [
“(...) But I myself have never gone to the dentist, nobody has encouraged me, my mother didn’t tell let’s goto the dentist daughter, I’ll take you there... so, lose everything!”
“I have never heard that mother told us to brush our teeth... there wasn’t a toothbrush where we lived... here nobody talks too much about these things, because they know that to take care of the teeth cost a lots of money.”
Popular culture, the acquired knowledge throughout life and individual or collective beliefs were the factors that mostly permeated the speeches seized in connection with the acquisition and maintenance of oral health. The literature points to similar developments, in particular, at-risk populations with socioeconomic and educational deficit [
“About the salt I know that does not spoil, because my grandfather said when he had toothache, go there and make brine and rinse the mouth, it will kill the microbes. It was his way, he knew it would work... he could never go to the dentist and never brushed too, he didn’t know how to pick up a brush...”
Another related aspect of the subjects were oral hygiene habits, emphasizing the importance of flossing. The perception of collectors reveals the relationship between poor oral health and financial condition again, emphasizing the difficulty on access to dental supplies.
“I don’t have money to pay for a dental floss. I use plastic baggie (...) if there’s not floss I use this, at least I’m doing something.”
“To clean well, it’s necessary to use the toothbrush and to substitute the dental floss, I usually use the stitching yarn.”
The replacement of traditional dental cleaning agents, with a view to improving the quality of care, was also found in the literature [
Oral diseases, mostly don’t present any risk to life; however, its evolution, and injury prevalence are important in individual and collective life impacts, and should be considered in the management of public policies [
The usage of dental services is persuaded by different and multiple determinants including sociodemographic factors, perceived need, and importance attributed to oral health [
“I had to go to the dentist, it was a horrible pain! It swelled, I could not leave the house and could not work. Horrible pain, pan! My husband charges me when I don’t go to work, because I help him to pay all the household bills.”
“I went to boot, it was sore, with root already appearing. I can’t feel pain, because I need to be good to take care of my husband and my kids.”
Although the toothache affects people from different social stratum, some researches suggest higher prevalence of pain in individuals with greater individual and social vulnerability [
The perception of collectors of recyclable materials on access to public dental services endorse the classical interpretation, linking it strongly to the simple presence of the professional in their field of work, the number of professionals, the availability of an appointment, the severity of their oral condition and being treated well by the dentist:
“(...) We arrive (public health service) with pain and still takes luck that has dentist to boot, he/she always finds a way, and treats us well... but there are people who need to score here for three or four months.”
“A person will not get pain, public health needs to improve, it’s not the lack of the dentist, that’s necessary to have more people working in oral health.”
The ways which are welcomed to step into a unit of the public health service was also cited, exposing a sense of exclusion across their working conditions:
“But there are people who work there (public health service) and don’t like we walked there... is, they think that we’re dirty. But when it hurts (tooth) I’ll go even. But the dentist says nothing, he has no disgust of our work.”
“If I could pay (dental treatment) I wasn’t going there... I know we are talking about we’re garbage. But just because I work with recyclables do I need to have my mouth spoiled?”
Although the few researches in the area of oral health to study the relationship between social exclusion and access to public health services, it is known that the there is the difficulty of access in Brazil and even more evident in groups of vulnerable individuals. To confront this reality it should be worked more with internal policies that eliminate the influence of social stereotypes in the deliberations of the daily work of health professionals [
Faced with the discovery of insights into the etiology and practice of care for oral health among collectors of recyclable materials, which show themselves, mostly fueled by beliefs and values collectively instituted, being linked to cognitive, economic, political, behavioral conditions, situational and social, it becomes essential to look at the value of action planning and health services.
Thus, it is suggested that the adoption of protective, educational and interceptors practice in oral health, among disadvantaged communities socially, is also developed guided by qualitative information about the problem and ways to address it, with a view to empowering individuals and communities.