Oral health inequalities:

time for action

29th September 2016, EADPH, Budapest.

Professor Richard G Watt

Department of Epidemiology & Public Health, UCL

Outline of Presentation

Outline nature of oral health inequalities & gradients

Stress importance of social determinants framework

Highlight need for radical public health approach to

reduce inequalities

Outline importance of international collaborative action

and networks

www.ucl.ac.uk/dph

Nature of health inequalities

Dental Public Health

ucl.ac.uk/dph

HEALTH DIFFERENCES

INEVITABLE POTENTIALLY AVOIDABLE

ACCEPTABLE UNACCEPTABLE, UNFAIR

INEQUALITIES

Dahlgren & Whitehead (1991)

Life expectancy in countries in the WHO

European Region, 2010 (or latest available)

Source: WHO Health for all database, 2012

Life expectancy at birth (men)UK, Glasgow (Calton) 54

India 62

US, Washington D.C. (black) 63

Philippines 64

Lithuania 65

Poland 71

Mexico 72

Cuba 75

US 75

UK 77

Japan 79

US, Montgomery County (white) 80

UK, Glasgow (Lenzie N.) 82

Sources: WHO World Health Statistics 2007; Hanlon, Walsh & Whyte 2006; Murray et al. 2006

Social gradient in health

Life expectancy by social class

72

74

76

78

80

82

84

Social Class I Social Class II Social Class IIIN Social Class IIIM Social Class IV Social Class V

Lif

e ex

pec

tan

cy

Life expectancy by social class, England and Wales 1992-1996 (Marmot 2003)8

Health inequalities

Key public health challenge for

21st century

Oral health inequalities

SES and caries: systematic review

Low SEP is associated with a

higher risk of caries lesions

or experience

Association stronger in

developed countries.

Inequalities not due to

diagnostic and treatment

concepts

Schwendicke F, Dörfer CE, Schlattmann P, Page LF, Thomson WM, Paris S. J Dent Res. 2015; 94(1):10-8.

Examples

Local level

Deprivation and dental disease

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5

mean number of dmft

Inco

me S

up

po

rt (

%)

r=0.91

Dyer et al., (2010)

Avg. number of decayed (dt), missing (mt), filled (ft), teeth for 5 year old children in Islington 2003/04 by

school. ( Source:BASCD 2004)

0

0.5

1

1.5

2

2.5

3

3.5

4

School

Av

g.d

mft

Average of dt Average of mt Average of ft

Examples

National level

Inequalities: behaviours & impact

• Oral health behaviours varied by SES eg– Toothbrushing (72% vs 82%)

– Regular dental attendance (66% vs86%)

– Sugar drinks (13% vs 26%)

• Significant variation by SES on subjective impacts of oral disease eg– Pain (27% vs 11%)

– Two or more difficulties (39% vs 28%)

Probabilities of being edentate for adults by social class - ADHS.

Bernabé E and Sheiham A. (2014) Tooth loss in the United Kingdom-trends in social

inequalities: an age-period-and-cohort analysis. PLoS One, Aug 8;9(8).

Education gradients in self-rated oral and general

health, periodontal disease and heart disease

0

0.5

1

1.5

2

2.5

3

Perceived oral

health

Perceived

general health

Periodontitis Ischemic heart

disease

Od

ds

Ra

tio

Education>12 year

Education=12 years

Education<12years

(Sabbah et al, 2007; JDR)

Examples

International level

Source: IHME, Global Burden of Diseases (2013)

(age-standardized, both sexes, DALYs per 100,000)

Income-related inequalities in dental service

utilization, Europeans aged 50+ years

-20

0

20

40

60

80

Listl S. J Dent Res, 2011 * non-significant

*

*

Welfare state regimes in Europe: Anglo-Saxon, Bismarckian, Scandinavian, Southern(Ferrera’s typology) + Eastern

28

Results

Age-standardized prevalence of edentulousness by welfare state regime

0

5

10

15

20

25

30

Scandinavian Anglo-Saxon Bismarckian Southern Eastern29

Age-standardized prevalence of edentulousness by occupation and welfare state regime (Participants aged ≥45 years from 21 European countries)

0

5

10

15

20

25

30

Scandinavian Anglo-Saxon Bismarckian Southern Eastern

Managers and professionals Intermediate Manual workers

*

*

**

*

* P for trend ≤ 0.01

Guarnizo-Herreno et al, 2012

Results

Relative inequalities in no functional dentition by welfare state type

Welfare

State Regime

Socioeconomic position measure

Education Occupational class Subjective social status

RII 95% CI RII 95% CI RII 95% CI

Scandinavian 3.81 2.68 - 5.42 3.79 2.65 - 5.41 2.95 2.08 - 4.18

Anglo-Saxon 1.89 1.22 - 2.92 2.36 1.53 - 3.65 1.46 0.92 - 2.33

Bismarckian 2.22 1.74 - 2.84 1.59 1.27 - 2.00 1.46 1.14 - 1.85

Southern 1.79 1.21 - 2.65 1.91 1.24 - 2.94 2.15 1.58 - 2.92

Eastern 1.57 1.34 - 1.84 1.88 1.53 - 2.31 1.40 1.23 - 1.59

p-valuea <0.001 0.925 0.311

a p-value of the interaction between each SEP score and welfare state regime

31

1

2

3

4

5

Number ofmissing teeth

Less than good OH ≥1 oral impact

Re

lative

In

de

x o

f In

eq

ua

lity

England US

Relative inequalities in oral health measures, England & the US

Guarnizo-Herreño CC, Tsakos G, Sheiham A, Marmot MG, Kawachi I, Watt RG. BMJ, 2015

A. Education

Summary

Significant association

between clinical & subjective

oral health outcomes and

various SEP markers

Universal social gradient

Pattern across the life course

Inequalities exist in different

populations and settings

(Watt and Sheiham, 1999; Locker 2001; Hobdell et al ., 2012)

www.ucl.ac.uk/dph

Determinants of health

inequalities

DENTAL PUBLIC HEALTH

Oral health determinants

Bio-medical perspective

– Oral hygiene

– Sugars consumption

– Smoking and alcohol

– Exposure to fluoride

– Use of dental services

Paradigm shifts in

aetiological perspectives

Biological - biomedical approach

“Lifestyle” - public health behaviourism

Social determinants agenda

Social determinants of

health

www.who.int/social_determinants

The Social Determinants of Health

The poor health of the poor, the social gradient in health

within countries and the marked inequities between

countries are caused by:

Commission on Social Determinants of Health, 2008

Structural determinants

The unequal distribution in power, money, goods and services,

globally, nationally and locally

Conditions of daily life

The consequent unfairness in the immediate, visible

circumstances in people’s lives - access to schools, education,

health care, conditions of work and leisure, their homes,

communities, towns or cities

Social determinants of health

CSDH (2008)

Complex influences on health

Healthindividuals & communities

Wider influences

Lifestyle factors

Socio economic & political context

Macro economic policies

Social & welfare policies

Political autonomy

Discrimination

Globalisation

Socioeconomic Position

Social Class

Gender

Ethnicity

Occupation

Income

Material & social circumstances

Living & working conditionsFood securitySocial capital

Behaviour & biological factorsAge, genetics

Inflammatory ProcessesInfections

Psychosocial FactorsStress

Perceived controlSocial support

Health ServicesQuality of care

Appropriate AccessEvidenced based preventive

orientation

Oral health inequalities

&

Social gradient

Structural Determinants(Political and economic drivers)

Intermediary Determinants(Circumstances & risk for oral disease)

Adapted CSDH Framework (WHO 2008)

Conceptual Framework for Social Determinants of Oral Health Inequalities

Prevailing preventive

paradigm

Does this approach work?

Effectiveness Reviews Brown (1994)

Schou and Locker (1994)

Kay and Locker (1996)

Sprod, Anderson and Treasure

(1996)

Kay and Locker (1998)

Department of Human

Services (1999)

Watt and Marinho (2005)

Yevlahova and Satur (2009)

PHE (2014)

Limitations with education &

clinical prevention

Ineffective in reducing inequalities - fails to tackle causes

Costly - high professional

input

Non sustainable

Duplication of effort

Public apathy and

resistance

Inverse prevention law

Even when interventions are successful at

improving health across the population,

they may increase health inequalities.

(Gordon et al., 1999; Lorenc et al., 2012)

Scottish dental health education intervention

(Schou L, Wight C: Does dental health education affect inequalities in dental health? Community Dent Health 1994, 11(2):97-100.)

0

5

10

15

20

25

30

35

40

45

Beforeintervention

1 monthafter

4 monthafter

Plaque index=0

Non-deprived Deprived

60

65

70

75

80

85

Beforeintervention

1 monthafter

4 monthafter

No bleeding

Non-deprived Deprived

Summary

Dominant preventive approach ineffective

in tackling inequalities

Too clinical, narrowly focused on high risk

groups

Urgent need to adopt a radically different

approach

www.ucl.ac.uk/dph

Time for change in approach

Dental Public Health

ucl.ac.uk/dph

Implications for health

improvement

What does the evidence

show?

Effective policies to reduce inequalities

Structural changes in environment

Legislative and regulatory controls

Fiscal policies

Starting young

Community action

Improving accessibility of services

Prioritizing disadvantaged population groups

(WHO 2003; Bambra et al., 2010; Lorenc et al., 2012)

Ineffective interventions – increase inequalities

Information based campaigns (mass media

programmes)

Written materials (leaflets and posters)

Campaigns reliant on people taking the initiative

to opt in

Health education campaigns designed for the

whole population

(MacIntyre, 2007; Lorenc et al., 2012)

Policy Levels for Tackling

Inequalities in Health

www.ucl.ac.uk/dph

Role of clinical staff

Dental Public Health

ucl.ac.uk/dph

Role of clinical teams

Population focus

Delivery of evidence based

prevention

Organisational review of

practice policy – access,

equity

Partnership working

Local advocacy role

www.ucl.ac.uk/dph

Role of dental associations

Dental Public Health

ucl.ac.uk/dph

Role of national dental

associations

Recognition of the importance of

addressing inequalities & role of

profession

Training and capacity building across

profession

Advocacy and lobbying role – policy arena

Partnership working across professional

groups

www.ucl.ac.uk/dph

Public health approach

Dental Public Health

ucl.ac.uk/dph

Is sugar the new tobacco?

New Nutrition Guidance WHO (2015)

Theme 1

Produce

and

import

less

Theme 2

Use less

Theme 3

Sell less

Theme 4

Market

less

Theme 5

Advise to

eat less

Theme 6

Eat less

Upstream Downstream

Theme 1

Produce

and

import

less

Theme 2

Use less

Theme 3

Sell less

Theme 4

Market

less

Theme 5

Advise to

eat less

Theme 6

Eat less

Upstream Downstream

Taxes on sugary products

Retail restrictions on high sugar foods

Reduce portion sizes of sugary foods

Nature of evidence

At least 6 systematic and narrative reviews of international evidence

Published from 2010-2015

Evidence from economic modelling, lab experiments, ecological

analysis and limited number of experimental studies (very few

RCTs)

Range of diet and other outcomes assessed (very few health

outcomes)

Opportunities for action

Action possible in wide range of levels and settings

Role of EADPH at international level lobbying & evidence

Community and local level

– Local Authority settings eg leisure facilities

– Schools, nurseries etc – part of food policy

Inequalities agenda

Partnership working essential

Need for careful community engagement

www.ucl.ac.uk/dph

Collaborative international action

DENTAL PUBLIC HEALTH

Thursday 21st May 2015

Royal College of General Practitioners, London, UK

Launch ConferenceIn Partnership with Public Health England

www.icohirp.com

Conclusions

Global challenge of addressing oral health inequalities

Need to recognise limitations of biomedical preventive

model

Time to adopt a social determinants approach in oral

health policy at local, national & international levels

Importance of collaborative international action

Thank you

r.watt@ucl.ac.uk

www.ucl.ac.uk/dph

www.icohirp.com