Addressing oral health inequalities through oral health promotion

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.


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Published: January-April 2016, HPC

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