pathways to oral health inequalities - eadph budapest pathways to oral... · pathways to oral...

Pathways to Oral Health

Inequalities

Georgios TsakosDept. of Epidemiology and Public Health, UCL

Budapest

30th September 2016

Dental Public HealthW: www.ucl.ac.uk/dphT: @UCL_DentalPH

Outline

Explaining oral health inequalities: pathways

Materialist

Behaviours

Psychosocial factors

Life course approach

Do they actually explain inequalities? Evidence from

general and oral health

Implications for action

W: www.ucl.ac.uk/dphT: @UCL_DentalPH

The shape of oral health inequalities: social gradient


SES and caries: systematic review

Lower SEP associated with

higher risk of caries lesions

or experience.

Association stronger in

developed countries.

Inequalities not due to

diagnostic and treatment

concepts

Risk of bias in included

studies (evidence graded

as low or very low).

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


CSDH conceptual framework for action on the social determinants of health

Solar O, Irwin A (2010): A Conceptual framework for action on the social determinants of health. Social Determinants

of Health Discussion Paper 2 (Policy and Practice). Geneva: World Health Organization.


Explanations for health inequalities

Materialist

Cultural/behavioural

Psycho-social

Life course

1. Bartley M (2004): Health Inequality: An Introduction to Theories, Concepts and Methods. Cambridge: Polity Press.

2. Newton JT, Bower EJ. Community Dent Oral Epidemiol 2005; 33(1): 25-34.


Materialist pathways

Emphasizes the role of the external environment

Income / wealth and what it enables: access to goods

and services; protection from exposures to material

(physical) risk factors such as:

Poor housing;

Diet of low nutritional value;

Physical hazards at work;

Hazardous outside environments;

Pollution;

Barriers to accessing public services.

Does not sufficiently explain the social gradient in

health.


Bartley M (2004): Health Inequality: An Introduction to Theories, Concepts and Methods. Cambridge: Polity Press.

Income-related inequalities in dental service utilization, Europeans aged 50+ yrs

-20

0

20

40

60

80

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

*

*


Cultural/behavioural pathways

• Health inequalities as a result of differences in risky

health behaviours (mainly diet, oral hygiene,

smoking, alcohol consumption, and physical

activity) between socio-economic groups

• Suggests that people from lower socioeconomic

backgrounds are more likely to engage in health

compromising behaviours than people from higher

socioeconomic backgrounds, leading to higher

levels of disease

• Due to differences in beliefs, norms and values

influenced by education and social class



Inequalities in health behaviours

Higher socio-economic position is related to:

Lower probability of smoking.

Higher probability of healthy diet.

Higher probability of physical exercise.

Better weight control.

Lower probability of alcohol overconsumption.

Higher probability to participate in screening.

All these affect health

Lantz, House, Lepkowski, Williams, Mero, Chen (1998). JAMA; 279(21):1703-8.

Pill, Peters, Robling (1995). J Epidemiol Community Health; 49(1): 28-32.

Steptoe and Wardle (1999). Psychology and Health; 14: 391-402.

Wardle and Griffith (2001). Epidemiology and Community Health; 55(3): 185-190.

Wardle, Mccaffery, Nadel, Atkin (2004). Social Science and Medicine; 59(2): 249-261.

Wardle, Robb, Johnson, Griffith, Brunner, Power, Tovée (2004). Health Psychology; 23(3): 275-282.


Do health behaviours “explain” health inequalities?

American Changing Lives survey (n=3617): nationally

representative sample, longitudinal study.

All-cause mortality showed clear SES gradient (age –

sex – race - urbanicity adjusted).

When health risk behaviours (cigarette smoking,

alcohol drinking, sedentary lifestyle, relative body

weight) were considered, the SES gradient persisted.

“Socioeconomic differences in mortality are due to a

wider array of factors and, therefore, would persist even

with improved health behaviours among the

disadvantaged”

Lantz, House, Lepkowski, Williams, Mero, Chen (1998). JAMA; 279(21):1703-8.


Health Inequalities and Behaviours

How much of the social gradient in health can be

explained by health-related behaviours?

• “Health behaviours attenuated the association

of SES with mortality by 75%

in Whitehall II but only by

19% in GAZEL”• They are likely to be major

contributors of health

inequalities only in contexts

with a marked social

characterisation of health

behaviours

Stringhini S, Dugravot A, Shipley M, Goldberg M, Zins M, Kivimäki M, Marmot M, Sabia S, Singh-Manoux A. PLoS

Med 2011; 8(2): e1000419.


Broadbent JM, Zeng J, Foster Page LA, Baker SR, Ramrakha S, Thomson WM. J Dent Res. 2016; 95(7): 808-813.

SEP to oral health… through Behaviours


0

0.5

1

1.5

2

2.5

Education = 12 yrs Education < 12 yrs

Od

ds

rati

o fo

r per

ceiv

ed p

oo

r ora

l hea

lth

adjusted for confounders

adjusted also for behaviours

Do health behaviours “explain” oral health inequalities?

Sabbah, Tsakos, Sheiham, Watt (2009). Soc Sci Med; 68(2): 298-303.

US adults (NHANES III)


Do health behaviours “explain” oral health inequalities?

Representative sample of 9th and 11th grade students

across Pennsylvania

Lower SES associated with higher prevalence of DMFT

and higher prevalence of severe caries

Lower SES associated with worse behavioural patterns

“Disparities in caries experience, however, cannot be

accounted for by SES-associated differences in

brushing, flossing, sealant use, fluoride exposure, or

recency of use of dental services”

Polk DE, Weyant RJ, Manz MC. Community Dent Oral Epidemiol 2010; 38(1):1-9.


Health Behaviours and Inequalities

Corresponding to the social gradient in health, the

social gradients for health behaviours are ubiquitous.

“Poor people behave poorly”1.

People in the lower social grades are more likely to

engage in a wide range of risk related behaviours

and less likely to practice health promoting ones.

Behavioural risk factors cluster cross-sectionally and

accumulate longitudinally.

But the health behaviours gradient is not sufficient to

fully explain the health gradient

1. Lynch J (1997). Soc Sci Med; 44 (6):809-819.


Psycho-social pathways

• Social inequality influences health through

perceptions of control and social standing, namely, a

person’s position in society relative to others.

• People of lower SEP are hypothesized to experience

higher levels of psychosocial stress

• Due to having less control over their lives, lower levels

of social support and less job security



Does social capital explain social inequalities in inequalities?

• Systematic review:

• Social capital associated with socioeconomic

inequalities in health

• Some studies showed that “social capital has a

stronger positive effect on health for people with a

lower socioeconomic status”

• Evidence for both a buffer and a dependency effect

Uphoff E, Pickett K, Cabieses B, Small N, Wright J. Int J Equity Health 2013; 12(1):54.


Does stress “explain” health inequalities?

0

0.5

1

1.5

2

2.5

education = 12yrs education < 12yrs education = 12yrs education < 12yrs

Ischaemic Heart Disease Periodontitis

Od

ds R

ati

o

adjusted for confounders

adjusted also for allostatic load

Sabbah, Watt, Sheiham, Tsakos (2008). J Epidemiol Community Health; 62(5): 415-20.


Gupta E, Robinson PG, Marya CM, Baker SR. J Dent Res. 2015; 94(10): 1362-1368.

SEP to oral health… through Psychosocial factors


Life course model

• Health status at any given age is the result not only of

current conditions but also of prior living conditions

(starting before birth)

• Health inequality is a result of inequalities in the

accumulation of material, social, psychological, and

biological advantages and disadvantages over the

life course of individuals

• Health and social circumstances influence each

other over time.



Adler NE, Stewart J, Cohen S, Cullen M, Diez Roux A, Dow W, Evans G, Kawachi I, Marmot M (2007): Reaching for a

Healthier Life: Facts on Socioeconomic Status and Health in the U.S. The John D. and Catherine T. MacArthur Foundation

Research Network on Socioeconomic Status and Health.

http://www.macses.ucsf.edu/downloads/Reaching_for_a_Healthier_Life.pdf

The Dynamic Relationship Between Health and Socioeconomic status


http://www.macses.ucsf.edu/downloads/Reaching_for_a_Healthier_Life.pdf

Strategic Review of Health Inequalities in England:

The Marmot Review – Fair Society Healthy Lives

Inequalities across the life course –emphasis on younger ages

W: www.ucl.ac.uk/dphT: @UCL_DentalPcH

Fiscal Measures

National &/or local policy initiatives

Legislation/Regulation

Healthy Settings- HPS

Community Development

Training other professional groups

Media Campaigns

School dental

health education

Chair side dental

health education

Clinical Prevention

‘Upstream’

Healthy Public Policy

‘Downstream’

Health Education &

Clinical Prevention

Upstream - downstream interventions


Watt RG. Community Dentistry Oral Epidemiology 2007; 35: 1-11.

Oral Health Promotion - Childsmile

Childsmile: national programme designed to improve

oral health of children in Scotland and reduce

inequalities in dental health and access to services 1.

Childsmile Core: Every child provided with a Dental Pack

(toothbrush, tube of 1000ppm F-toothpaste and

information leaflet) on at least six occasions by the age of

5 yrs.

Childsmile Practice: referral by health visitor straight to a

dental practice or to a Dental Health Support Worker

Childsmile Nursery and Childsmile School: F varnish for

children aged 3+ yrs living in the most deprived areas.

Initial outcomes: reductions in dental caries of 3-year-

olds across SEP groups in Scotland2.

1. http://www.child-smile.org.uk/

2. McMahon AD, Blair Y, McCall DR, Macpherson LM. BMC Oral Health 2011; 11:29.


http://www.oralhealthplatform.eu/best-practices/

Best Practices in Europe

Best practices in

oral health

promotion and

prevention

across Europe

Initial step -

“Live” toolkit


Intervention in one municipality of Japan

Creation of 'salons' (or community centers) to

boost social participation as a way of preventing long-

term disability in senior citizens

Participation in the centre associated with 2.52 times

higher odds for reporting excellent or very good self-

rated health.

“Investing in community infrastructure to boost

the social participation of communities may help

promote healthy ageing ”.

Community Psychosocial Interventions

and Oral Health Inequalities

Ichida Y, Hirai H, Kondo K, Kawachi I, Takeda T, Endo H. Soc Sci Med 2013; 94:83-90.


German population, aged 14-79 years

Modelling caries increments and costs over 10 years

Caries increment: 82.27 million teeth at 20% tax on SSBs;

83.02 million teeth without sugar tax.

Reduction especially in younger (rather than older)

individuals and those with low income.

Treatment costs savings: 8 billion Euros.

Additional tax revenue: 38 billion Euros.

“…a 20% sales tax on SSBs is likely to reduce caries

increment, especially in young low-income males,

thereby also reducing inequalities in caries”.

Sugar tax and Oral Health Inequalities

Schwendicke F, Thomson WM, Broadbent JM, Stolpe M. J Dent Res 2016 (in press).


Summary

Emphasis on potential explanations (pathways) in order

to understand and address inequalities

Different pathways – not one simple or complete

explanation

Social gradient also for health behaviours – it does not

fully “explain” the social gradient (inequalities) in oral health

Interventions should focus on wider social determinants

(“causes of the causes”) – “upstream” emphasis

Common Risk Factor Approach – integration of oral

health into general health

To change behaviours, we need to change the

environment


What good does it do to treat people's illnesses ...

… and then send them back to the conditions

that made them sick? (Marmot)


Thank you for your attention

[email protected]

www.ucl.ac.uk/dph

www.icohirp.com

MSc Dental Public Health

www.ucl.ac.uk/mscdph

Dental Public HealthW: www.ucl.ac.uk/dphT: @UCL_DentalPH

@UCL_DentalPH

UCL Department of Dental Public Health

http://www.ucl.ac.uk/dph

http://www.icohirp.com

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