social determinants of health and oral health

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SOCIAL DETERMINANTS OF HEALTH AND ORAL

HEALTH PRESENTED BY Puneet Chahar

PG 2nd yearDept. Public Health Dentistry,

Maulana Azad Institute of Dental Sciences

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CONTENTS Introduction

Concept of Health Dimensions of health and spectrum of health Determinants of Health

Definition of Social Determinants of health History of emergence of Social Determinants of Health SDH approaches at Country Level- Some studies Theories of SDH Models explaining SDH Oral Health inequalities Oral Health inequalities- Evidence Explanations of Oral Health Inequality Summary References

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CONCEPTS OF HEALTH

Health is multidimensional: it is not only merely the presence or absence of disease, but also has

social, psychological and cultural determinants and consequences.

The WHO defined Health as: “A complete state of physical, mental and social well-being and not

merely absence of disease or infirmity.” (WHO 1948)

New definition of health recognizes the inextricable links between and individual and her/his

environment. It is known as , socio-ecological definition.

In recent years, this statement has been amplified to include the ability to lead a “socially and

economically productive life” (WHO 1978)

K. Park. Medicine and social science. Textbook of Preventive and Social Medicine. 23rd Ed. Jabalpur; M/s Banarsidas Bhanot Publishers. 2013

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CONCEPTS OF HEALTH

Operational definition-

1. Broad sense- a condition or quality of human organism expressing the adequate functioning

of the organism in a given condition, Genetic or Environment.

2. Narrow Sense-

A. There is no obvious evidence of disease, and that a person is functionally normal. i.e.

conforming within the normal limits of variation to the standard for health criteria

generally accepted for ones age, sex, community, and geographic region;

B. The several organs of the body are functioning adequately in themselves and in relation

to one another, which implies a kind of equilibrium or homeostasis- condition relatively

stable but which may vary as human beings adapt to internal and external stimuli.K. Park. Medicine and social science. Textbook of Preventive and Social Medicine. 23rd Ed. Jabalpur; M/s Banarsidas Bhanot Publishers. 2013

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ORAL HEALTH

A standard of health of the oral and related tissues which enables an individual to eat, speak and

socialize without active disease, discomfort, or embarrassment and which contributes to general

well-being.

(UK Department of health, 1994)

The retention throughout life of a functional, aesthetic and natural dentition of not less than 20

teeth and not requiring a prosthesis. (WHO

1982)

Peter S. Essentials of preventive and community dentistry. 4th ed. New Delhi: Arya(Medi) Publishing House; 2010.

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DIMENSIONS OF HEALTH

• PHYSICAL • MENTAL• SOCIAL• EMOTIONAL• VOCATIONAL• OTHERS

DIMENSIONS


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CONCEPT OF WELLBEING & SPECTRUM OF HEALTH

WELL BEING

STANDARD OF LIVING

LEVEL OF LIVING

QUALITY OF LIFE

OBJECTIVE SUBJECTIVE


Dynamic

Health- lie along a continuum

No single cut off point

INTRODUCTION- DETERMINANTS OF HEALTH

DETERMINANTS OF HEALTH - Factors influencing the health of the individual or population

are known as determinants of health.

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DETERMINANTS OF

HEALTH

Biological

Behavioural and socio-

cultural

Environmental

Socio-economic condition

s

Health Services

Ageing, gender, Other factors


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INTRODUCTION- DETERMINANTS OF HEALTH

No risks occur in isolation, and many have their roots in complex chains of events spanning

long periods of time. Each event has its cause and may have many causes. The chain of events

leading to an adverse health outcome can be both proximal and distal.

Proximal factors act directly or almost directly to cause diseases, while distal factors are further

back in the causal chain and act via a number of intermediary causes

Petersen PE. Sociobehavioural risk factors in dental caries – international perspectives. Community Dent Oral Epidemiol 2005; 33: 274–9.

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PROXIMAL AND DISTAL DETERMINANTS OF HEALTH

The proximal determinants, which act on both micro and macro levels, often include

1. Lifestyle Or Behavior (E.G. Alcohol, Fat, Tobacco, Fruit And Vegetable Consumption),

2. Socioeconomic Environment (Including Macro-economic Measures Such As Wealth),

3. Demography (E.G. Elderly Proportion Of The Total Population),

4. Physical Environment (E.G. Air Pollution By Oxides Of Sulphur, Nitrogen Or

Carbon)and

5. Host Constitution.

Distal determinants of health include the national, institutional, political, legal, and cultural

factors that indirectly influence health by acting on the more proximal factors, their interrelated

mechanisms, levels, trends, and distributions.Arah O A, Westert G P, Delnoij D M, Klazinga N S. Health system outcomes and determinants amenable to public health in industrialized countries: a pooled, cross-sectional time series analysis. BMC Public Health 2005;5(1):81.

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PROXIMAL AND DISTAL DETERMINANTS OF HEALTH


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BIOLOGICAL DETERMINANTS

The physical & mental traits of every human being are determined by the nature of his genes.

The genetic makeup is unique in the sense it cannot be altered.

Genetic origin, E.g., Chromosomal anomalies, errors of metabolism, mental retardation.

Medical genetics offers hope for prevention & treatment of a wide spectrum of diseases, thus the

prospect of better medicine & longer & healthier life.

A positive health advocated by WHO implies that a person should be able to express as

completely as possible the potentialities of his genetic heritage.


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BEHAVIOURAL & SOCIO CULTURAL CONDITIONS

Life style denotes “ the way that people live”, reflecting a whole range of social values, attitudes

& activities.

It is composed of cultural & behavioural patterns & life long personal habits

(Alcoholism,smoking)that have developed through the process of socialization.

Life styles are learnt through social interaction with parents & peer groups, friends, siblings &

through school & mass media.

Coronary heart disease, obesity, lung cancer, drug addiction are associated with life style.


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ENVIRONMENT

Hippocrates who first related disease to environment, climate, water, & air.

Environment is classified as “internal” & “external”.

Internal environment of a man pertains to each & every component part, every tissue organ &

organ system & their harmonious functioning within the system.

External or macro environment consists of those things to which man is exposed after

conception.

It can be divided into physical, biological & psychosocial components , any or all of which affect

can affect the health of man & his susceptibility to illness.


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ENVIRONMENT

Some epidemiologists use the term “micro environment” or domestic environment or personal

environment which reflects a person’s way of living & lifestyle. E.g., eating habits, personal

habits.

The other environment includes occupational environment, socio economic environment, moral

environment.


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SOCIO ECONOMIC CONDITIONS

The health of a person is primarily dependent upon the level of socio economic development.

E.g., Per Capita income, GNP, education, nutrition, employment, housing & political system

of the country.


POLITICAL SYSTEM

OCCUPATION

EDUCATIONECONOMIC

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HEALTH SERVICES

Health services are seen as essential for social & economic development. There is a strong

correlation between GNP & Expectation of life at birth & the overall health status of the given

population.

Health &Family welfare services aim at improving the health condition of the population.

India being a signatory member , to realize Heath For All has chalked out strategies like the

PHC, CHC & other peripheral infrastructure.

The National preventive programmes such as Immunization programme, AIDS Control

programme, Malaria Eradication Prog, Filaria Control Prog, ICDS, The Mid day Meal

programme, Family Welfare programmes & Other non communicable disease programmes aim

at prevention, promotion & maintenance of the health status of the population.


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Other factors

Gender

Ageing populations

Systems outside the formal health care systems- Health related sectors (Food and Agricultural,

Education, Inductry, Social welfare, Rural development, adoption of policies, employement

opportunity, increases wages)


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SOCIAL DETERMINANTS OF

HEALTH AND ORAL HEALTH

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INTRODUCTION- SOCIAL DETERMINANTS OF HEALTH

SOCIAL ENVIRONMENT- denotes the complex of psychosocial factors influencing the health of the

individual and the community.

Unique to man and include cultural values, customs, customs, habits, belief, attitudes, morals,

religion, education, income, occupation, standard of living, community life and social and

political organisation.

Effect is clearly reflected in the differences in morbidity pattern of Rural vs Urban areas/

Developing vs Developed countries.

Affect multiple problems- Obesity, CHD, Hypertension, STDs, Alcoholism, Accidents etc.

Gupta MC, Mahajan BK. Textbook of Preventive and Social Medicine. 3rd edition. New Delhi: Jaypee brothers medical publishers (P) LTD; 2005

Psychosocioeconomic Environment

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SOCIAL SCIENCES

Social sciences – Includes 5 concepts

‘social sciences’ is applied to those disciplines which are committed to the scientific examination of

human behaviour.

Sociology Anthropology Psychology

Economics Political Science

Behavioural Sciences

Gupta MC, Mahajan BK. Textbook of Preventive and Social Medicine. 3rd edition. New Delhi: Jaypee brothers medical publishers (P) LTD; 2005

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SOCIAL CONTEXT OF MEDICINE

Last few decades have shown that social and economic factors have as much influence on

health as medical interventions.

Poverty, malnutrition, poor sanitation, lack of education, inadequate housing,

unemployment, poor working conditions, cultural and behavioural factors all predispose to

ill-health.

There has been a shift from earlier concept of visualizing disease in terms of a specific germ

to involvement of "multiple factors" in causation of disease.

As a result of new outlooks, concepts of sociology are increasingly being used in study of

disease in human societies.


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SOCIAL CONTEXT OF MEDICINE

Health is influenced by four sets of variables - individual

predispositions, ecological predispositions, current

circumstances, and opportunities.

These variables are in turn influenced by major

sources of social changes: economic, political,

educational and other systems

Specialists in community health, clinical medicine,

epidemiology are seeking cooperation and help of social

scientists in understanding problems such as social

component of health and disease, "illness behaviour"

of people, efficient medical care and study of medical

institutions. K. Park. Medicine and social science. Textbook of Preventive and Social Medicine. 23rd Ed. Jabalpur; M/s Banarsidas Bhanot Publishers. 2013

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CONCEPTS IN SOCIOLOGY

CUSTOMS

Folkways

Mores

Taboos

CULTURE

LAWS

SOCIETY

COMMUNITY

SOCIAL INSTITUTIONS

SOCIALIZATION

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SOCIETY

The word society is derived from the root words socius, meaning individual and societa, meaning

group.

Society is a group of individuals who have organized themselves and follow a given way of life,

and sociology is the study of individuals as well as groups in a society.


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Social determinants of health

The World Health Organisation defines the social determinants of health as: “… the

circumstances in which people are born, grow up, live, work, and age, and the systems put in

place to deal with illness. These circumstances are in turn shaped by a wider set of forces:

economics, social policies, and politics”.

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History of determinants of health The recognition that social and

environmental factors decisively influence people's health is ancient

The sanitary campaigns of the 19th

century reflected awareness of the powerful relationship between people's social position, their living conditions and their health outcomes.

1950s: emphasis on technology and disease-specific campaigns

International public health during this period was characterized by the proliferation of "vertical" programmes -- narrowly focused, technology-driven campaigns targeting specific diseases such as malaria, smallpox, TB and yaws.

The 1960s and early 70s: the rise of community-based approaches

Thomas McKeown- Significant reduction in mortality rate of Infectious disease occurred long before the introduction of Vaccination

program and Treatment

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The importance of high-end medical technology was downplayed, and reliance on highly trained medical professionals was minimized. Instead, it was thought that locally recruited community health workers could, with limited training, assist their neighbours in confronting the majority of common health problems.

WHO and UNICEF published a joint report examining Alternative approaches to

meeting basic health needs in developing countries.

Health education and disease prevention were at the heart of these strategies.

social factors such as poverty, inadequate housing and lack of education were the real

roots underlying the proximal causes of morbidity in developing countries

Director-General of WHO (1976)- action to address non-medical determinants was

necessary to overcome health inequalities and achieve "Health for All by the year

2000"

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The crystallization of a movement: Alma-Ata and primary health care

The PHC model as articulated at Alma-Ata “explicitly stated the need for a comprehensive health strategy that not only provided health services but also addressed the underlying social, economic and political causes of poor health”

Accordingly, health work under the HFA banner regularly incorporated, at least on

paper, intersectoral action to address social and environmental determinants.

PHC included among its pillars intersectoral action to address social and environmental health determinants.

First International Conference on Health Promotion – OTTAWA CHARTER, identified

eight key determinants ("prerequisites") of health: peace, shelter, education, food,

income, a stable eco-system, sustainable resources, social justice, and equity.

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In the wake of Alma-Ata: "Good health at low cost"

"Good health at low cost" (GHLC) was the title of a conference sponsored by the Rockefeller Foundation in April-May 1985.

The conference closely examined the cases of three countries (China, Costa Rica and Sri Lanka) and one Indian state (Kerala) that had succeeded in obtaining unusually good health results (as measured by life expectancy and child mortality figures), despite low GDP and modest per capita health expenditures, relative to high-income countries.

Marmot M, Bell R. Health equity and development: The commission on social determinants of health. European Review, 2010;18(01):1-7.

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PREVIOUS DOUBTS

SICKNESS ABSENTEEISM occurs when employees miss work for reasons stemming from

health problems.

The rate of sickness absenteeism is linked to the overall health of the workforce and also to specific

factors in each individual profession.

Workplace policies and national standards also impact the rate of sickness absenteeism as do

cultural norms and personal attitudes among workers.

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CONCEPTS OF PUBLIC HEALTH IN INDIABHORE COMMITTEE- Appointed in 1943.

Recommended comprehensive remodeling of health services.1. Integration of preventive and curative health services at all levels.2. Hospital-based health care system.3. Development of primary health centres in two stages.4. Training in Preventive and Social Medicine.

The short-term planA PHC for every 40000 population.PHC to be manned by 2 doctors, 4 PHN, 4 Midwife, 1 Nurse, and others.District unit with 2500 bedded hospital.

The long-term planA primary health unit for every 10-20 thousand population with 75 beds.Secondary unit with 650 bedded hospital.District unit with 2500 bedded hospital.

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INTERNATIONAL HEALTH AGENDAS

a focus on technology-based medical care and public health interventions

an understanding of health asa social phenomenon, requiring more complex forms of intersectoral policy action

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SDH- APPROACHES AT COUNTRY LEVEL

The direct roots of contemporary efforts to identify and address socially-determined health inequalities

refers to :

1. The Canadian Lalonde Report (1974)

Biomedical: all aspects of health, physical and mental, developed within the human body as

influenced by genetic make-up;

Environmental: all matters related to health external to the human body, over which the individual

has little or no control, including the physical and social environment;

Lifestyle: the aggregation of personal decisions (i.e. over which the individual has control) that

can be said to contribute to, or cause, illness or death;

Health care organization: includes medical practice, nursing, hospitals, nursing homes, medical

drugs, public health services, paramedic services, dental treatment and other health services.

http://en.wikipedia.org/wiki/Mental_health

http://en.wikipedia.org/wiki/Human_body

http://en.wikipedia.org/wiki/Genetics

http://en.wikipedia.org/wiki/Hospital

http://en.wikipedia.org/wiki/Public_health

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2. The Black Report in the United Kingdom (1980, Townsend and Davidson) – Amongst all

reported conditions the mortality and morbidity rates were higher in people from lower

socioeconomic groups.

3. Whitehall studies of comparative health outcomes among British civil servants (Sir Michael

Marmot)-

The initial prospective cohort study, the Whitehall I Study, examined over 18,000 male

civil servants, and was conducted over a period of ten years, beginning in 1967.

A second cohort study, the Whitehall II Study, examined the health of 10,308 civil

servants aged 35 to 55, of whom two thirds were men and one third women.

https://en.wikipedia.org/wiki/Cohort_study

https://en.wikipedia.org/wiki/Cohort_study

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The initial Whitehall study found lower grades, and thus status, were clearly associated

with higher prevalence of significant risk factors. These risk factors include obesity,

smoking, reduced leisure time, lower levels of physical activity, higher prevalence of

underlying illness, higher blood pressure, and shorter height. Controlling for these risk

factors accounted for no more than forty percent of differences between civil service

grades in cardiovascular disease mortality. After controlling for these risk factors, the

lowest grade still had a relative risk of 2.1 for cardiovascular disease mortality compared to

the highest grade.

https://en.wikipedia.org/wiki/Social_status

https://en.wikipedia.org/wiki/Obesity

https://en.wikipedia.org/wiki/Leisure

https://en.wikipedia.org/wiki/Blood_pressure

https://en.wikipedia.org/wiki/Cardiovascular_disease

https://en.wikipedia.org/wiki/Death

https://en.wikipedia.org/wiki/Relative_risk

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2. In the UK the Acheson Review highlighted the importance of the socioeconomic

determinants of health inequalities and identified a range of social and welfare policies to

promote the health and well being of the population

3. Alameda County Study - The Alameda County Study is a study of certain residents of

Alameda County, California which examines the relationship between lifestyle and health.

http://en.wikipedia.org/wiki/Alameda_County,_California

http://en.wikipedia.org/wiki/Health

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The specific vocabulary of "social determinants of health" came into increasingly wide use

beginning in the mid-1990s.

Tarlov (1996) was one of the first to employ the term systematically.

Tarlov identified four categories of health determinants: genetic and biological factors; medical

care; individual health-related behaviours; and the "social characteristics within which living takes

place".

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WHY SOCIAL DETERMINANTS OF HEALTH ?

Lifestyle approach (Focussing only on Changing behaviour of patients like smoking, alcohol

and drug misuse, poor eating etc. )- FAILURE

1. Ineffective and very costly

2. Diverts attention from causes of the causes.

Behaviours are enmeshed within the social, economic and environmental conditions of living.

Individual behaviour are largely determined by conditions in which they live

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LIMITATIONS OF THE PSYCHOLOGICAL THEORITICAL BASE

Studies which reveal a weak relationship between psychological concepts such as motivations,

beliefs, attitudes and opinions with actual behaviour.

More elaborate and complex psychological models also have limited value.

HEALTH BELIEF MODEL are based on the hypothesis that a sense of susceptibility to

disease induces behaviour change.

1. Evidence from many studies have however, revealed the importance of social or other

motivating factors rather than health concerns as driving behaviour change.

2. Rational and Logical basis of human behaviour, which is not a true reflection of human

experience in the real world where social, environmental and political factors greatly

determine behaviourWatt RG. Emerging theories into the social determinants of health: implications for oral health promotion. Community Dent Oral Epidemiol 2002; 30: 241–7.

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EXISTING THEORIES

HEALTH EDUCATION MODEL-

Dominated

Emphasis on lifestyle and behavioural change

Costly and Ineffective

Narrowly focussed- defined diseases, targeted at changing the behaviours of high risk

individuals

Common finding of the reviews was the lack of theory underpinning many interventions.

The emphasis is increasingly now on reducing health inequalities through action on changing the

determinants of Health. Watt RG. Emerging theories into the social determinants of health: implications for oral health promotion. Community Dent Oral Epidemiol 2002; 30: 241–7.

VICTIM BLAMING REDUCTIONISM/ DOWMSTREAM

APPROACH

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EXISTING THEORIES

In a recent meta-analysis of studies using the well-known models of ‘Theory of Reasoned Action’

and ‘Theory of Planned Behaviour’, only 40-50% of variance of intention and 20-40% variance of

behaviour were explained by the models.

Diverting limited resources ‘downstream’ away from the true aetiological factors determining

population health is a highly politicized approach, and as such should be resisted by public health

advocates

Sutton S. Predicting and explaining intentions and behaviour: How well are we doing ? J App Soc Psycho] 1998;28:1317-38.

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LOOK FOR ALTERNATIVE THEORIES

INTERVENTIONS to reduce oral health inequalities need to be guided by theoretical frameworks

that are developed from an analysis of the origins and processes underlying health disparities.

THEORIES OF SOCIAL DETERMINANTS OF HEALTH

Life Course Perspective- NEWTON 2005, WATT 2002

Salutogenic theory- AORON ANTONOVSKY, 1987

Social Capital- WATT 2002

Fundamental cause theory, Lind and Pehlam

Common RiskFactor Approach- SHIEHAM AND WATT, 2000

Watt RG. Emerging theories into the social determinants of health: implications for oral health promotion. Community Dent Oral Epidemiol 2002; 30: 241–7.

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A life course perspective considers an individual’s disease status as a marker of their past social

position.

1. The importance of early life circumstances on health in adulthood have been highlighted in

birth cohort studies.

2. A relationship between low birth weight and later socioeconomic circumstance has been

demonstrated.

The life-course perspective places particular emphasis upon the social context and the interaction

between people and their environments in the passage through life.

Advantage and disadvantage may cluster cross-sectionally and accumulate longitudinally, thus

contributing to the creation of health and social inequalities in society.

LIFE COURSE ANALYSIS


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Introduction- Health and inequality: the importance of the life course

Previous Experiences.

Deterioration in living and working

conditions

ADVANTAGES/DISADVANTAGES – GEN.

Example- The development of oral hygiene habits may be sensitive to the socioeconomic environment in which people live during their childhood

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Introduction

The life course approach to studying chronic disease aetiology is not merely a collection of

longitudinal data or the use of a particular study design or analytical method.

Rather, the unique feature of this approach is a theoretical framework which assumes and tests

a temporal ordering of exposure variables and their interrelationship with a specific outcome

Nicolau B, Thomson WM, Steele JG, Allison PJ. Life course epidemiology: concepts and theoretical models and its relevance to chronic oral conditions. CommunityDent Oral Epidemiol 2007;35:241–9.

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Life course models

Life course models- Not mutually exclusive and may operate together

1. Critical Period Model

2. Critical Social Transitions

3. Life Course Accumulation Model

Pathway model

4. Life course accumulation model- RISK clustering

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Example of different models of life course approach

Nicolau B, Thomson WM, Steele JG, Allison PJ. Life course epidemiology: concepts and theoretical models and its relevance to chronic oral conditions. Community Dent Oral Epidemiol 2007;35:241–9.

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SALUTOGENIC MODEL (origins of health) Rather than focus attention on understanding the nature of disease and its associated risk behaviours, this

approach considers the factors responsible for creating and maintaining good health.

Antonovsky's theories reject the "traditional medical-model dichotomy separating health and illness". He

described the relationship as a continuous variable, what he called the "health-ease versus dis-

ease continuum".


https://en.wikipedia.org/wiki/Dichotomy

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SALUTOGENIC MODEL (origins of health)

“Health is relative on a continuum and the most important research question is what causes health

(salutogenesis) not what are the reasons for disease (pathogenesis)”

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The central hypothesis of the salutogenic model is that stressors are a standard feature of human

existence and that individuals and communities with a stronger sense of coherence are better equipped

to deal with them and therefore maintain good health and well being.

In salutogenic theory, people continually battle with the effects of hardship. These ubiquitous forces are

called GENERALIZED RESOURCE DEFICITS (GRDS). On the other hand, there are GENERALIZED

RESISTANCE RESOURCES (GRRS), which are all of the resources that help a person cope and are

effective in avoiding or combating a range of psychosocial stressors. Examples are resources such as

money, ego-strength, and social support.

Typical GRRs are money, knowledge, experience, self-esteem, healthy behaviour, commitment, social

support, cultural capital, intelligence, traditions and view of life.Lindström B Eriksson M. Contextualizing salutogenesis and Antonovsky in public health development. Health promotion international. 2006;21(3):238-244.

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Source- Google imagesGRR- This referred to a property of a person, a collective or a situation which, as

evidence or logic has indicated, facilitated successful coping with the inherent stressors of human existence.

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Two studies produced conflicting results in relation to patients coping strategies in response to

oral cancer. In a more recent study with young people, sense of coherence was identified as a

psychosocial determinant of adolescent’s pattern of dental attendance.

By promoting salutary factors within communities this approach would aim to move the

population more towards the health end of the health–disease continuum.


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The salutogenic model contributes to the maintenance and development of health and quality of life

(QoL), i.e. the process and outcome of the principles of the OC.

The metaphor of the river and the life cycle are new ways of demonstrating the paradigm shift

provided by the Salutogenesis and health promotion in relation to public health and medicine.

Source- Google images

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SOCIAL CAPITAL

Social capital has relational, material and political aspects. We suggest that, although the relational

properties of social capital are important (eg, trust, networks), the political aspects of social capital

are perhaps under recognised.

A common line of argument for the social capital approach has been that income inequality is a

major determinant of national mortality rates; the mechanism by which this occurs is that increased

income inequality reduces “social capital,” which in turn results in poorer health in the relevant

communities; and the most likely explanation for this mechanism involves psychosocial factors.

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SOCIAL CAPITAL

Putnam defines social capital as ‘features of social organisation, such as civic participation, norms

of reciprocity, and trust in others, that facilitate co-operation for mutual benefit’.

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SOCIAL CAPITAL

Assessing the level of social trust that operates within a community, how safe people feel together,

how much help people give each other for their own and collective benefit and the degree of

involvement in social and community issues.

1. Based upon Wilkinson’s work on the importance of relative poverty research has

demonstrated a consistent and strong relationship between income distribution and life

expectancy in a selection of developed countries

2. A recent ecological study in Brazil has assessed the relationship between income inequality,

social cohesion and dental caries levels in 12-year-oldschoolchildren.


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Fundamental cause theory

Link & Phelan, 1995

Why association between SES & mortality has persisted despite radical changes in diseases

& risk factors presumed to explain it ?

Enduring association results because SES embodies an array of resources – money,

knowledge, prestige, power & beneficial social connections that protect health; no matter

what mechanisms are relevant at any given time

Phelan JC, Link BG & Parisa. Social Conditions as Fundamental Causes of Health Inequalities: Theory, Evidence & Policy Implications. Journal of Health & Social Behavior 2010 51: S28- S40

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Fundamental cause theory

Essential features of fundamental social cause of health inequalities

1. Influences multiple disease outcomes; not limited to only one or a few diseases or

health problems

2. Affects disease outcomes through multiple risk factors

3. Involves access to resources that can be used to avoid risks or to minimize

consequences of disease once it occurs

4. Association is reproduced over time via replacement of intervening mechanisms

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IMPLICATIONS OF THEORIES OF SDH Potential implications of theories for oral health promotion:

1. Focus Of Interventions: Determinants Of Oral Health;

2. Strategies Adopted: Complementary Range Of Actions;

3. Community Empowerment And Involvement: Active

Participation Of Target Populations;

4. Timing Of Interventions: Window Of Opportunity To

Maximise Health Gain;

5. Partnership Working: Multidisciplinary Collaboration.

HEALTH PROMOTING SETTING


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MODELS EXPLAINING UNIVERSAL HEALTH DETERMINANTS

1. Dahlgren & Whitehead’s Social Determinants of Health Rainbow


The first layer is personal behaviour and ways of living that can promote or damage health. –eg choice to smoke or not-Individuals are affected by friendship patterns and the norms of their community.

The next layer is social and community influences, which provide mutual support for members of the community in unfavourable conditions. But they can also provide no support or have a negative effect.

The third layer includes structural factors: housing, working conditions, access to services and provision of essential facilities.

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2. Evans & Stoddart Field Model of Health & Wellbeing- Evans et al. (1990) sought to "construct an

analytic framework within which such evidence can be fitted, and which will highlight the ways in

which different types of factors and forces can interact to bear on different conceptualizations of

health."

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MODELS EXPLAINING UNIVERSAL HEALTH DETERMINANTS Rather than a voluntary act amenable to direct intervention, behavior can be seen as an intermediate

factor that is itself shaped by multiple forces, particularly the social and physical environments and

genetic endowment.

At the same time, behavior remains a relevant target for intervention. The model also differentiates

among disease, health and function, and well-being. They are affected by separate but overlapping

factors, and therefore, indicators selected to monitor health improvement programs may need to

differ depending on which outcome is of primary interest.

The model also reinforces the interrelatedness of many factors. Outcomes are the product of

complex interactions of factors rather than of individual factors operating in isolation. It was

suggested that the interactions among factors may prove to be more important that the actions of

any single factor.

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3. Model described by Brunner & Marmot

Biological pathways are shown to exist in

a social context

Social structures are linked to individual

health via three interlinking material,

psychosocial and behavioural pathways.

psychosocial stress and social capital fit

into the ‘psychological’ and ‘social

environment’ sections of the model,

respectively.

Newton JT, Bower EJ. The social determinants of health: new approaches to conceptualizing and researching complex causal networks. Community Dent Oral Epidemiol 2005; 33: 25–34

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MODELS EXPLAINING UNIVERSAL HEALTH DETERMINANTS The model locates risk factors for oral diseases in society as well as in the individual, forcing an

examination of social processes which cannot be reduced to the sum of individual behaviours.

Allows the exploration of how individual oral health practices are shaped by local cultures and

shared contexts


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4. Chandola et al. model for complex pathways


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5. CONCEPTUAL FRAMEWORK ON SDH

Solar, O., & Irwin, A. (2007). A conceptual framework for action on the social determinants of health.

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HEALTH INEQUALITY AND HEALTH INEQUITIES

Health inequities are avoidable inequalities in health between groups of people within countries

and between countries . These inequities arise from inequalities within and between societies.

Examples of health inequities between countries: • the infant mortality rate (the risk of a baby dying between birth and one year of age) is 2 per 1000 live births in Iceland and over 120 per 1000 live births in Mozambique;

Examples of health inequities within countries: • in Bolivia, babies born to women with no education have infant mortality greater than 100 per 1000 live births, while the infant mortality rate of babies born to mothers with at least secondary education is under 40 per 1000

70

HEALTH INEQUALITY AND HEALTH INEQUITIES

It can also be argued that global health inequity occurs when countries fail to meet their commitments to

global health, for example, by continuing failure to meet the target for official development aid of

0.7% of GDP agreed at the United Nations in 1970, or by failing to meet the commitments agreed at

Alma Ata in 1978 to provide access to primary care for all, or by the current failure to meet the

Millennium Development Goals set in 2001.

Disparity is the quantity that separates a group from a reference point on a particular measure of health

that is expressed in terms of a rate, proportion, mean, or some other quantitative measure. (HP2010).

71

Health Disparities, health Equity and Burden

Burden- The difference in the number of persons affected between groups. Generally, the larger the

group—the larger the burden.

72

Oral health inequity and issues of the Dental Workforce in India

One of the key factors contributing to oral health inequity is lopsided Dental Care workforce

planning in India.

1. Deficient Manpower Planning and Projection

2. Geographic Imbalance

3. Inadequate Workforce in Rural Area

Missing link causing this unfortunate situation is the absence of a primary health care

approach in dentistry.

Yadav P, Kaur B, Shrivastava R, Shrivastava S. Oral Health Disparities: Review. IOSR Journal of Dental and Medical Sciences 2014;13:69-72

73

ORAL HEALTH INEQUALITIES

Even in countries with well-developed dental health care systems, and where community water

fluoridation programmes exist, oral health inequalities, although less marked, still persist.

Individuals at the top of the social hierarchy enjoy better health than those immediately below

them, and as one goes down the social scale, health deteriorates further.

The slope of the social gradient in health varies, being less steep in more egalitarian countries

such as Sweden where there are fewer inequalities in income and social position.

Reducing the avoidable differences in health status can be seen as an issue of social justice.

74

ORAL HEALTH INEQUALITIES- EVIDENCE

Lopez and colleagues recently reported a social gradient in a range of periodontal disease

outcomes in a large sample of Chilean high school students.

All periodontal outcomes investigated followed a stepwise social gradient with paternal income and

parental education being the most influential variables assessed.

An inverse linear gradient between an index of multiple deprivation and two oral health

outcomes, self-reported missing teeth and Oral Health Impact Profile (OHIP-14) scores

Sanders AE, Spencer AJ, Slade GD. Evaluating the role of dental behaviour in oral health inequalities. Community Dent Oral Epidemiol 2006;34:71–79.

Lo`pez R, Ferna´ndez O, Baelum B. Social gradients in periodontal diseases amongst adolescents. Community Dent Oral Epidemiol 2006;34:184–96

75


Armfield JM, Mejia CG, Jamieson ML. Socioeconomic and psychosocial correlates of oral health. Int Dent Journal 2013; 63: 202–209

76


WHO International Collaborative Studies (ICS-I or -II)


77


Petersen PE. Socio behavioural risk factors in dental caries – international perspectives. Community Dent Oral Epidemiol 2005; 33: 274–9.

78


Petersen PE. Oral health behaviour of 6-year-old Danish children. Acta Odontol Scand 1992;50: 57–64.

79


Holst D. Oral health equality during 30 years in Norway. Community Dent Oral Epidemiol 2008; 36: 326–334.

80

ORAL HEALTH INEQUALITIES- EXAMPLES

Oral health data from the Dunedin Multidisciplinary Health and Development Study in New

Zealand - Low paternal socioeconomic position was significantly associated with higher caries

and periodontal disease experience at 26 years.

Investigation of the determinants of oral health inequalities in an Australian adult population,

Sanders et al. showed that dental behaviours (dental visiting and dental self care) accounted for

little, if any, of the socioeconomic gradient in oral health.

Sanders AE, Spencer AJ. Childhood circumstances, psychosocial factors and the social impact of adult oral health. Community Dent Oral Epidemiol 2005;33:370–7.

Sanders AE, Spencer AJ, Slade GD. Evaluating the role of dental behaviour in oral health inequalities. Community Dent Oral Epidemiol 2006;34:71–79.

81


In the maxilla, having no replacement was positively associated with lower categories for each

of the three SES indicators.

Low occupational status was the single predictor for suboptimal dental prostheses

In the mandible, occupational status showed no association with the prosthetic status, whereas

low educational level and low household income were determinants for having no replacement

Low household income was the single determinant for suboptimal replacement of missing teeth.

Mundt T, Polzer I, Samietz S, Grabe HJ, Messerschmidt H, Do¨ren M, Schwarz S, Kocher T, Biffar R, Schwahn C. Socioeconomic indicators and prosthetic replacement of missing teeth in a working-age population–Results of the Study of Health in Pomerania (SHIP). Community Dent Oral Epidemiol 2009; 37: 104-115

82


Jimenez M, Dietrich T, Shih M-C, Li Y, Joshipura KJ. Racial ⁄ ethnic variations in associations between socioeconomic factors and tooth loss. Community Dent Oral Epidemiol 2009; 37: 267–275

83


Sanders AE, Slade GD, Turrell G, John Spencer A, Marcenes W. The shape of the socioeconomic–oral health gradient: implications for theoretical explanations. Community Dent Oral Epidemiol 2006; 34: 310–19.

84


Neto JMS, Nadanovsky P. Social inequality in tooth extraction in a Brazilian insured working population. Community Dent Oral Epidemiol 2007; 35: 331–336.

85


Lo´pez R, Ferna´ndez O, Baelum V. Social gradients in periodontal diseases among adolescents. Community Dent Oral Epidemiol 2006; 34: 184–96.

86


Borrell LN, Crawford ND. Social disparities in periodontitis among United States adults 1999–2004. Community Dent Oral Epidemiol 2008; 36: 383–391.

87


Shiboski CH, Schmidt BL, Jordan RCK. Racial disparity in stage at diagnosis and survival among adults with oral cancer in the US. Community Dent Oral Epidemiol 2007; 35: 233–240.

88


Simone M. Costa 1 , Carolina C. Martins 1 , Maria de Lourdes C. Bonfim 1 , Lívia G. Zina 2 , Saul M. Paiva 1 , Isabela A et al., A Systematic Review of Socioeconomic Indicators and Dental Caries in Adults Int. J. Environ. Res. Public Health 2012, 9, 3540-3574

89



90



91

HEALTH INEQUALITY- EXPLANATIONS

4 possible explanation for Health Inequalities: (Townsend and Davidson, 1982)

1. Artefact- That inequalities are not real, but rather a function of how social class and health are

measured.

2. Selection process- This explanation proposes that people in poor health drift down the social

scale. Based upon this analysis, health therefore determines social class position.

3. Lifestyle Effects- The social distribution of risk behaviour such as smoking and drug misuse

is higher amongst the lower social class.

4. Materialistic and Structural Factors- Emphasis upon the effects of poverty and

disadvantage on Health.

92

HEALTH INEQUALITY- EXPLANATIONS

Diderichsen’s model of “the mechanisms of health inequality

1. Social contexts, which includes the structure of society or the social relations in society,

create social stratification and assign individuals to different social positions.

2. Social stratification in turn engenders differential exposure to health-damaging conditions

and differential vulnerability, in terms of health conditions and material resource

availability.

3. Social stratification likewise determines differential consequences of ill health for more and

less advantaged groups (including economic and social consequences, as well differential

health outcomes per se).

Solar, O., & Irwin, A. (2007). A conceptual framework for action on the social determinants of health.

93

ORAL HEALTH INEQUALITY- EXPLANATIONS

Social inequality in oral health is a universal phenomenon, higher levels of

disease are found in more deprived areas in the industrialized and non-

industrialized world alike.

Explanations for inequalities in oral health:

1. The materialist explanation

2. Cultural/behavioural explanations

3. Psychosocial perspective

4. The life course perspectiveSisson KL. Theoretical explanations for social inequalities in oral health.Community Dent Oral Epidemiol 2007; 35: 81–88.

94

THE MATERIALIST EXPLANATION Emphasizes the role of the external environment, factors which are

beyond the individuals’ control.

Materialist explanations emphasize factors which are linked to an individual’s position in the social

structure, arguing that factors such as income and education are not directly responsible for

inequalities in health.

Traditional behavioural explanations focus on the behavioural and lifestyle choices made by people from

different socioeconomic backgrounds.

People from low socioeconomic backgrounds are more likely to engage in behaviours that are damaging

to their health than people from higher socioeconomic backgrounds and consequently this leads to higher

levels of disease.

CULTURAL/BEHAVIOURAL EXPLANATIONS

Sisson KL. Theoretical explanations for social inequalities in oral health.Community Dent Oral Epidemiol 2007; 35: 81–88.

95

PSYCHOSOCIAL PERSPECTIVE

Health inequalities result from differences in the experience of psychological stress between

socioeconomic groups.

Individuals from lower socioeconomic backgrounds are hypothesized to experience higher

levels of psychosocial stress resulting from

1. a higher number of negative life events,

2. having lower levels of social support

3. less control at work

4. less job security and

5. living in communities with lower levels of trust and higher levels of crime and antisocial

behaviour Sisson KL. Theoretical explanations for social inequalities in oral health.Community Dent Oral Epidemiol 2007; 35: 81–88.

96

THE LIFE COURSE PERSPECTIVE

The life course perspective states that health status at any given age, for any given birth cohort is a

result not only of current conditions but also of the embodiment of prior living conditions from

conception onwards.

Sisson KL. Theoretical explanations for social inequalities in oral health.Community Dent Oral Epidemiol 2007; 35: 81–88.

97

RECOMMENDATIONS

World Health Organisation. Health promotion evaluation:recommendations to policy makers

FRAMEWORK FOR TACKLING SOCIAL DETERMINANTS OF HEALTH

98Watt RG. Social determinants of oral health inequalities: implications for action. Community Dent Oral Epidemiol 2012; 40 (Suppl. 2): 44–48.

RECOMMENDATIONS


1. The most challenging policy agenda focuses upon mitigating the effects of social stratification, in other

words attempts at reducing the social and economic gradients to create a more egalitarian, fairer and just

society.

• Involves higher-level action on improving social mobility, access to high-quality education and

training, taxation policy, and the reform of welfare and social benefits to protect the most

vulnerable in society

2. Policy action to create more supportive social conditions and environments for oral health could

include policies in preschools, schools and colleges, workplaces, hospitals and other community settings.

• policy on water fluoridation, safety of play areas and school recreation facilities, and food and nutrition

policy to encourage healthier eating

99


3. Policies in this area seek to build individual’s and community’s capabilities and resilience to

maintain good health and well-being.

• Oral health literacy programmes, interventions that support and develop self-confidence,

strengthen social networks and enhance coping strategies

4. Directly relates to oral health as there is good scientific evidence that oral diseases have a greater

impact in terms of pain/discomfort, functional limitations, and social and economic impacts amongst more

socially disadvantaged groups compared to their more affluent peers.

100

RECOMMENDATIONS

101Watt RG. From victim blaming to upstream action: tackling the social determinants of oral health inequalities. Community Dent Oral Epidemiol 2007; 35: 1–11

POLICY LEVEL

“Failure to include social, economic, environmental and political factors in any analysis of health

behaviours ultimately results in a very negative and victim blaming understanding which can lead to

the development of potentially harmful and largely ineffective health policies”

102

Bunton R, Murphy S, Bennett P. Theories of behavioural change and their use in health promotion: some neglected areas. Hlth editor Res 1991;6:153–62.

RECOMMENDATIONS

Crombie and colleagues identified the

following policies:

1. Taxation And Tax Credits,

2. Old Age Pensions, Sickness And

Rehabilitation Benefits,

3. Maternity And Child Benefits,

4. Unemployment Benefits,

5. Housing Policies,

6. Labour Market, Social Inclusion And

Care Facilities 103Watt RG. From victim blaming to upstream action: tackling the social determinants of oral health inequalities. Community Dent Oral Epidemiol 2007; 35: 1–11

Recent public health strategy in Sweden

1. Participation in society,

2. Economic and social security,

3. Conditions in childhood and adolescence,

4. Healthier working life and

5. Environmental change

104

RECOMMENDATION FOR INDIA

Reduce income differentials and poverty through progressive taxation and the provision of

adequate income support for those in poverty.

Reduce unemployment through labour market policies that strengthen the position of those at

greater risk of unemployment

Implement community development programme and behavioural strategies for the

disadvantaged population

Reducing the barriers to regular dental attendance and promoting regular dental attendance

for low-socio-economic groups may reduce oral health inequalities to some extent.


105

RECOMMENDATION FOR INDIA

High risk groups should be identified among the underprivileged for targeted dental health

education efforts and delivery of more intensive dental care services

Appropriate oral health information from an early age within a compulsory school education

Program appears necessary to enhance health literacy and lessen inequalities in dental health.

Improving access to health care be a part of global fight against poverty and the reduction of

social inequalities

Reducing racial/ethnic dental health disparities which are mostly socioeconomically driven

requires polices that recognize the multilevel pathways underlying them.


SUMMARY

106

The Goal to eliminate disparities remain undefined.

When is a disparity eliminated?

When has health equity been achieved ?

107

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adult oral health. Community Dent Oral Epidemiol 2005;33:370–7.

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inequalities. Community Dent Oral Epidemiol 2006;34:71–79.

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social determinants of health and oral health

Health & Medicine