School academic climate and oral health (tooth loss) in adolescents

health was affected by the school climate of low expectation about the future. Alternatively, the rate of participation in ENEM into schools might represent other unmeasured variables such as parental expectations on their children’s future since this expectation might indirectly impact on the health of their offspring. Nevertheless, our finding suggests that the improve- ment of school academic climate might positively affect the health of our young generation [41]. The main limitation of our study is our cross-sectional design, which precludes causal infer- ence. Our response rate to the survey was also low, although a high percentage (87.0%) of schools agreed to take part in this study. Another limitation is that 16% of our study sample were missed the oral exams. We ended the oral examinations after visiting each school at least three times to search for students who had missed earlier opportunities to receive an oral examination. By this time, three months had already passed after the administration of the sur- vey, and we considered that the time elapsed was too long to consider using the data from the students who missed their oral examinations. Educational aspiration was assessed at the Table 2. Multilevel adjustment including Social Vulnerability Index. Parameters Empty model (Model 1) Random intercept, fixed effects contextual variables (Model 2) Random intercept, fixed effects individual variables (Model 3) Random intercept, fixed effects (individual + contextual variables) (Model 4) Fixed part Individual factors

Constant 0.26 [0.22,0.32] 0.17 [0.14,0.21] 0.07 [0.05,0.10] 0.06 [0.04,0.08] 16–19 yrs vs 14-15yrs 1.36 [1.03,1.78] 1.29 [0.98,1.70] Female vs male 1.00 [0.79,1.25] 1.00 [0.79,1.26] Mother’s level of schooling (< 9 years of study vs � 9 years) 1.49 [1.18,1.89] 1.42 [1.12,1.79] Family allowance (yes vs no) 1.78 [1.40,2.25] 1.80 [1.42,2.28] Dental anxiety (yes vs no) 1.36 [0.95,1.95] 1.37 [0.95,1.96] Self-perception of oral health (Fair/ poor vs Excellent/very good/good) 1.69 [1.33,2.16] 1.66 [1.30,2.11] Periodontitis (1or+ vs 0) 0.92 [0.55,1.56] 0.90 [0.54,1.52] Decayed tooth (1or+ vs 0) 1.90 [1.50,2.40] 1.88 [1.49,2.37] Contextual factors (School level) Participation in the National High School Examination (low vs high) 1.74 [1.30,2.33] 1.42 [1.09,1.85] Regular vs Full-time school 1.17 0.87,1.57] 1.12 [0.87,1.45] Social Vulnerability Index by neighborhood (high vs low) 1.26 [0.93,1.69] 1.31 [1.00,1.73] Random part Area level variance (Random intercept) 0.14[0.05,0.37] 0.01[0.00,2.89] 0.01[0.00,0.50] 1.01e-34 PCV& -92.86% -92.86% -99.99% Median Rate Ratio MRR = 1.42 MRR = 1.10 MRR = 1.12 MRR = 1 2 Res log-likelihood 1625.76 1608.15��� 1504.77��� 1490.17��� Observations 1237 1237 1237 1237 Exponentiated coefficients; 95% confidence intervals in brackets � p < 0.05 �� p < 0.01 ��� p < 0.005 PCV&: Proportional change in variance. https://doi.org/10.1371/journal.pone.0233505.t002 PLOS ONE School academic climate and tooth loss in adolescents PLOS ONE | https://doi.org/10.1371/journal.pone.0233505 May 21, 2020 7 / 11