Social determinants of health and oral health

SOCIAL DETERMINANTS OF
HEALTH AND ORAL HEALTH
PRESENTED BY
Puneet Chahar
PG 2nd year
Dept. Public Health Dentistry,
Maulana Azad Institute of Dental Sciences
1

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 2

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)
3K. Park. Medicine and social science. Textbook of Preventive and Social
Medicine. 23rd Ed. Jabalpur; M/s Banarsidas Bhanot Publishers. 2013

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.

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)
5Peter S. Essentials of preventive and community dentistry. 4th ed. New
Delhi: Arya(Medi) Publishing House; 2010.

DIMENSIONS OF HEALTH
• PHYSICAL
• MENTAL
• SOCIAL
• EMOTIONAL
• VOCATIONAL
• OTHERS
DIMENSIONS

CONCEPT OF WELLBEING & SPECTRUM OF
HEALTH
WELL
BEING
STANDARD
OF LIVING
LEVEL OF
LIVING
QUALITY
OF LIFE
7
OBJECTIVE SUBJECTIVE
K. Park. Medicine and social science. Textbook of Preventive and Social
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.
8
DETERMINANTS
OF HEALTH
Biological
Behaviour
al and
socio-
cultural
Environme
ntal
Socio-
economic
conditions
Health
Services
Ageing,
gender,
Other
factors

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

PROXIMALAND 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.
10Arah 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.

PROXIMALAND DISTAL DETERMINANTS OF HEALTH
11
Petersen PE. Sociobehavioural risk factors in dental caries –
international perspectives. Community Dent Oral Epidemiol 2005;
33: 274–9.

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.

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.

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.

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.

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
OCCUPATIONEDUCATIONECONOMIC

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.

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)

SOCIAL DETERMINANTS
OF
HEALTH AND ORAL HEALTH
19

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.
20Gupta MC, Mahajan BK. Textbook of Preventive and Social Medicine. 3rd edition. New Delhi: Jaypee
brothers medical publishers (P) LTD; 2005
Psychosocioeconomic Environment

SOCIAL SCIENCES
 Social sciences – Includes 5 concepts
 ‘social sciences’ is applied to those disciplines which are committed to the scientific examination of
human behaviour.
21
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

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.
22

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.

CONCEPTS IN SOCIOLOGY
24
CUSTOMS
Folkways
Mores
Taboos
CULTURE
LAWS
SOCIETY
COMMUNITY
SOCIAL INSTITUTIONS
SOCIALIZATION

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.

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”.
26

History of determinants of health
27
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

28
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"

29
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.

30
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.

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.
31

CONCEPTS OF PUBLIC HEALTH IN INDIA
32
BHORE 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 plan
A 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 plan
A primary health unit for every
10-20 thousand population with
75 beds.
Secondary unit with 650 bedded
hospital.
District unit with 2500 bedded
hospital.

INTERNATIONAL HEALTH AGENDAS
33
a focus on technology-
based medical care and
public health interventions
an understanding of health as
a social phenomenon, requiring more
complex forms of intersectoral policy action

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.
34

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.
35

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.
36

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.
37

 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".
38

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
39

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 behaviour
40Watt RG. Emerging theories into the social determinants of health: implications for oral health
promotion. Community Dent Oral Epidemiol 2002; 30: 241–7.

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.
41
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

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
42
Sutton S. Predicting and explaining intentions and behaviour: How well are we doing ? J
App Soc Psycho] 1998;28:1317-38.

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.
43
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

 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.
44
LIFE COURSE ANALYSIS

Introduction- Health and inequality: the
importance of the life course
Previous
Experiences.
ADVANTAGES/DISADVANTAGES – GEN. 45
Example- The development of oral hygiene habits may be sensitive to the socioeconomic
environment in which people live during their childhood

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. Community
Dent Oral Epidemiol 2007;35:241–9. 46

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
47

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. 48

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".

 “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)”
50

 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.
51
Lindström B Eriksson M. Contextualizing salutogenesis and Antonovsky in public
health development. Health promotion international. 2006;21(3):238-244.

52
Source- Google images
GRR- 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.

 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.

 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.
54
Source- Google images

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.
55

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’.
56

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.

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
58
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

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
59

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.
60
HEALTH PROMOTING SETTING

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.

MODELS EXPLAINING UNIVERSAL HEALTH DETERMINANTS
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."
62

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.
63

DETERMINANTS
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.
65Newton 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

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

DETERMINANTS
4. Chandola et al. model for complex pathways

5. CONCEPTUAL FRAMEWORK ON SDH
68
Solar, O., & Irwin, A. (2007). A conceptual framework for action on the social
determinants of health.

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.
69
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

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).
70

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.
71

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

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.
73

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
74
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

75Armfield 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)
Petersen PE. Sociobehavioural risk factors in dental caries – international perspectives.

77
Petersen PE. Socio behavioural risk factors in dental caries – international perspectives.

78
Petersen PE. Oral health behaviour of 6-year-old Danish children. Acta Odontol Scand
1992;50: 57–64.

79Holst D. Oral health equality during 30 years in Norway. Community Dent Oral Epidemiol 2008; 36: 326–334.

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.
80
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.

 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.
81
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

82Jimenez 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.

85Lo´pez R, Ferna´ndez O, Baelum V. Social gradients in periodontal diseases among adolescents. Community Dent Oral Epidemiol 2006; 34:
184–96.

86Borrell 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.

88Simone 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

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.
91

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).
92
Solar, O., & Irwin, A. (2007). A conceptual framework for action on the social
determinants of health.

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 perspective
93
Sisson KL. Theoretical explanations for social inequalities in oral health.

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.
94
CULTURAL/BEHAVIOURAL EXPLANATIONS

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
95

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.
96

RECOMMENDATIONS
97
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

FRAMEWORK FOR TACKLING SOCIAL
DETERMINANTS OF HEALTH
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

FRAMEWORK FOR TACKLING SOCIAL
DETERMINANTS OF HEALTH
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
103
Watt 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

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.
10
4
Yadav P, Kaur B, Shrivastava R, Shrivastava S. Oral Health Disparities: Review. IOSR Journal of Dental

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.
10
5
Yadav P, Kaur B, Shrivastava R, Shrivastava S. Oral Health Disparities: Review. IOSR Journal of Dental

SUMMARY
106
The Goal to eliminate disparities remain undefined.
When is a disparity eliminated?
When has health equity been achieved ?

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Community Dent Oral Epidemiol 2006;34:184–96
10. Sanders AE, Spencer AJ, Slade GD. Evaluating the role of dental behaviour in oral health inequalities.
Community Dent Oral Epidemiol 2006;34:71–79.
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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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22. 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.
23. 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,
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11
0

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11
1

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