By Ankur Singh, BDS, MSc Dental Public Health
Health inequalities are the potentially avoidable, unjust, unfair and unacceptable differences in health status between socially distinct groups.1 These inequalities in health status can occur in many dimensions such as income, wealth, gender, age, employment, ethnicity, indigenous status, caste, religion and sexual orientation among others.2 Regardless of the dimensions in which inequalities occur, the underlying factors for such differences are discrimination at population or individual level, lack of equitable public policies and unbalanced power distribution. These social factors or the fundamental causes of disease then impact the distribution of resources which include money, knowledge, power, prestige and the kinds of interpersonal resources such as social support and social network.3 Public health in the new era has a keen interest and a vital responsibility in reducing such gaps in health status across populations. The role of health promoters and public health advocates are central to this action. A departure from the traditional health education approach and individual behaviour change objectives to an inclusive approach in addressing the upstream social determinants of health clearly indicates this change.4
Oral health is integral to general health and most oral diseases are recognized as public health burdens due to their high prevalence, high healthcare costs, and effects on quality of life of individuals even when they are largely preventable.5, 6 According to the Global Burden of Disease report in 2013, untreated dental caries (tooth decay) is the most prevalent non-communicable disease, though it is largely preventable.6 Evidence suggests that tooth loss is associated with pre-mature mortality7 and increasingly studies have reported on the association between oral diseases such as tooth loss, dental caries as well as periodontal disease (gum inflammation) with hypertension, obesity and cardio-vascular diseases.8-12 Similarly, symptoms of oral diseases such as tooth ache also impacts school attendance in children and tooth decay is reported to impact school performance.13 As with other health outcomes such as mortality, cardio-vascular diseases, hypertension etc. significant levels of inequalities in tooth loss, dental caries, periodontal diseases and oral cancers have been reported worldwide.14
Non communicable diseases such as cancer, hypertension, obesity and oral diseases such as dental caries, periodontal disease and oral cancers also share common risk factors such as unhealthy diet, smoking, harmful alcohol use and stress.15 Additionally, these risk factors don’t occur randomly within populations and studies have reported social patterning in the distribution of both independent risk factors16 as well as their clusters.17 The behavioural determinants of oral health within individuals include high sugar consumption, smoking, tooth brushing, harmful alcohol use and dental attendance.14 Considering that the determinants of population levels of most oral diseases are socio-politically driven: – water fluoridation, food supply policies, public policies on tobacco control and health systems; oral health inequalities both within and between societies are quite pronounced.18 Thus, reducing oral health inequalities within societies demands an extensive involvement and collaborative action between policymakers, oral epidemiologists, dentists, general health workers, public health advocates, civil societies, interest groups, psychologists, community representatives and particularly a dedicated oral health promotion workforce.
Addressing these determinants further require the research, policy and health promoting actions to be based on strong theoretical foundations. Some limitations of traditional health education approaches which focus on behaviour change through increasing knowledge is that they are victim blaming, non-sustainable, ignores broader context and may actually further accentuate health inequalities due to unequal uptake of knowledge among different groups.19 Evidence also supports that individual level behaviour change interventions may differently impact different sections of the society.20 Theories proposed to explain health inequalities are material, behavioural, cultural, psychosocial and neo-material.21 These theories are primarily proposed to explain health inequalities within and between populations, and focus on the distribution of resources as well as the intervening mechanisms which cause disease.3 Therefore, it is necessary to reflect on them when designing oral health promotion interventions to reduce oral health inequalities. In addition, health inequalities and social exclusion are very context dependent, so these theories may have differential explanatory power to explain inequalities in different contexts.22
The missing link between the individualistic behaviour change theoretical models and the theoretical models proposed to explain oral health inequalities needs clarifications to strengthen the role of oral health promoters and the science of oral health promotion. In summary, oral health promotion is a logical answer to address the challenging oral health inequalities only when the actions are based on the principles of health promotion and on the understanding of theoretical basis of oral health inequalities. The oral health promotion specialist should lead this change and should strengthen collaborative efforts to eliminate or at least reduce oral health inequalities.
- Whitehead M and Dahlgren G. What can be done about inequalities in health? Lancet. 1991; 338: 1059-63.
- Kawachi I, Subramanian SV and Almeida-Filho N. A glossary for health inequalities. Journal of epidemiology and community health. 2002; 56: 647-52.
- Link BG and Phelan J. Social conditions as fundamental causes of disease. Journal of health and social behavior. 1995; Spec No: 80.
- Whitehead D. Health promotion and health education: advancing the concepts. J Adv Nurs. 2004; 47: 311-20.
- Listl S, Galloway J, Mossey PA and Marcenes W. Global Economic Impact of Dental Diseases. Journal of dental research. 2015; 94: 1355-61.
- Marcenes W, Kassebaum NJ, Flaxman E, et al. Global burden of oral conditions in 1990-2010: A systematic analysis. Journal of dental research. 2013; 92: 592-7.
- Watt RG, Tsakos G, de Oliveira C and Hamer M. Tooth loss and cardiovascular disease mortality risk–results from the Scottish Health Survey. PloS one. 2012; 7: e30797.
- Amar S, Gokce N, Morgan S, Loukideli M, Van Dyke TE and Vita JA. Periodontal disease is associated with brachial artery endothelial dysfunction and systemic inflammation. Arteriosclerosis, thrombosis, and vascular biology. 2003; 23: 1245.
- Choe H, Kim YH, Park JW, Kim SY, Lee SY and Jee SH. Tooth loss, hypertension and risk for stroke in a Korean population. Atherosclerosis. 2009; 203: 550-6.
- Darnaud C, Thomas F, Pannier B, Danchin N and Bouchard P. Oral Health and Blood Pressure: The IPC Cohort. Am J Hypertens. 2015; 28: 1257-61.
- Ostberg AL, Nyholm M, Gullberg B, Rastam L and Lindblad U. Tooth loss and obesity in a defined Swedish population. Scandinavian journal of public health. 2009; 37: 427-33.
- Peres MA, Tsakos G, Barbato PR, Silva DAS and Peres KG. Tooth loss is associated with increased blood pressure in adults – a multidisciplinary population?based study. Journal of clinical periodontology. 2012; 39: 824-33.
- Seirawan H, Faust S and Mulligan R. The impact of oral health on the academic performance of disadvantaged children. American journal of public health. 2012; 102: 1729-34.
- Watt RG, Heilmann A, Listl S and Peres MA. London Charter on Oral Health Inequalities. Journal of dental research. 2015.
- Watt RG and Sheiham A. Integrating the common risk factor approach into a social determinants framework. Community dentistry and oral epidemiology. 2012; 40: 289-96.
- Sabbah W, Tsakos G, Sheiham A and Watt RG. The role of health-related behaviors in the socioeconomic disparities in oral health. Soc Sci Med. 2009; 68: 298-303.
- Singh A, Rouxel P, Watt RG and Tsakos G. Social inequalities in clustering of oral health related behaviors in a national sample of British adults. Preventive medicine. 2013; 57: 102-6.
- Watt RG. From victim blaming to upstream action: tackling the social determinants of oral health inequalities. Community dentistry and oral epidemiology. 2007; 35: 1-11.
- Watt RG. Emerging theories into the social determinants of health: implications for oral health promotion. Community dentistry and oral epidemiology. 2002; 30: 241-7.
- McGill R, Anwar E, Orton L, et al. Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact. BMC public health. 2015; 15: 457.
- Bartley M. Health inequality : an introduction to theories, concepts, and methods. Cambridge, UK: Polity Press, 2004.
- Popay J, Escorel S, Hernandez M, Johnston H and Matieson J. Understanding and Tackling Social Exclusion. Final Report to the WHO Commission on Social Determinants of Health from the Social Exclusion Knowledge Network. Geneva: Social Exclusion Knowledge Network, World Health Organization, 2008.
Published: January-April 2016, HPC