Introduction
Marmot and Wilkinson (2003) argue that, “good health involves reducing levels of education failure, reducing insecurity and unemployment and improving housing standards.” This statement sounds very distant in relation to health. Superficially, good health could be perceived to include a healthy diet and improved medication. Marmot and Wilkinson’s proposition suggests a new perspective that had not been considered before. However, studies have been carried out to identify the authenticity of this suppositions and one common result has been found. Socio-political, economic and physical environments greatly affect the well being of an individual’s health. Similarly, the oral health of an individual is equally determined by these factors. For instance, Sabah and colleagues (2007) argue that social conditions of an individual directly relate to the status of his oral health. Good social conditions result into his good oral health and that of the society as a whole. Accordingly, this paper will identify how these health determinants affect oral health and hence cause inequalities in health status. Then, the paper will examine the strategies being developed to avoid the imbalance.
Importance of Dental Health
Before understanding the disparities in dental health and the factors leading to this, it is good that the importance of oral health is pointed out. To begin with, the World Health Organization (Petersen 2003) shows that the general health of any individual is to a great extend determined by his oral health. It posits that oral health directly affects the craniofacial complex which is responsible for conditions like oro-facial pain, lesions in the oral tissue; defects during child birth i.e. cleft lips, oral and pharyngeal cancer, et cetera. With an excellent oral health, the risk of being affected by these diseases is reduced greatly. Furthermore, research has proven that oral health is directly related to diabetes. To be precise, periodontal disease was found to be directly related to diabetes.
The organization further points out that oral health is a great determinant of an individual’s quality of life. This is determined by the close relationship between oral health and the craniofacial complex. Oral health allows an individual to have a healthy craniofacial complex which plays a role of allowing one to smile, speak, swallow, cry, taste, smell and many other day to day challenges. With impaired craniofacial complex, all these will be a struggle. An individual’s quality of life will be improved greatly (Petersen 2003).
In addition to the improvement of the quality of life, oral health has been identified as a factor that reduces premature mortality. This happens through the ability of detecting a disease in its early stages through dental examination (WHO 2007). Consequently, early detection increases the chances of disease control and equally longevity. Studies have shown that through oral examination, nutritional deficiency can be detected easily. In addition, other diseases that can be detected through oral examinations include oral cancer, disorders in the immunity system, injuries and microbial infections. This therefore means that through oral health, several other diseases can be detected and controlled hence increases a person’s life expectancy.
As shown above, oral health plays an important role in the society’s general health. However, there are more advantages associated with dental health. For example, dental health has a great financial implication in a country. Most affected by this are the developing countries which have been greatly ravaged by the two most common dental problems; dental caries and periodontal diseases. WHO (2007) show that 60-90% of children in industrialized countries are affected by dental caries. This was based on the survey carried out considering the DMFT model. This disease is also prevalent in Asia as compared to any other oral disease.
Health determinants and their role in oral health
The European Commission points out clearly that the best approach to tackling disease burdens is by addressing the social health determinants. These are personal characteristics including behavior and lifestyle, a community’s cultural practices and beliefs which eventually affect either positively or negatively the health status of its members, the given society’s living conditions which in turn affect its members’ access and need of medical services and the physical and social conditions that surround an individual. This section will identify these determinants and how they affect the health of an individual (European Commission 2009).
Lifestyle
Effects of lifestyle on the health of an individual can be approached from various dimensions. The daily actions by an individual which determines his lifestyle can have great impacts on his health. Lifestyle has been associated with several health problems with certain issues being linked to specific diseases while other diseases share common issues. In addition, life-situation specific issues related to lifestyle can also be important in understanding the role of lifestyle in determining an individual’s health. In addition, lifestyle can be associated closely with age and socioeconomic status of an individual. This is because an individual’s economic strength determines his lifestyle. The most common lifestyle issues that impact on the health of an individual include smoking which has been attributed to several diseases, nutrition which is essential for a healthy body, use of drugs and other substances and an individual’s mental health (European Commission 2009).
Secondly, socioeconomic status of an individual greatly determines his health status. The main issues in this field include employment of the individual or the society as a whole, the level of income of the individual and the community’s average, the level of education of an individual or the average of the community, the individual’s ethnicity et cetera. These issues are very important for any policy maker in order to reduce health inequalities. Without doubt, poverty is very likely to drive a person into activities that would put his health into jeopardy. On its part, the level of income is directly related to the level of education and in most cases, the ethnicity of the individual. These in return determine the lifestyle of an individual hence increasing the risk of poor health.
Next, the European Commission identifies the physical environment as a health determinant (European Commission 2009). Availability of hazards; both natural and manmade could pose great dangers on the general health of a community. For instance, air pollutants like wastes from industries, noises from vehicles and other industrial machines, poor housing conditions and internal environments, activities that contaminate the quality of water, exposure of individuals to chemicals, exposure of individuals to electromagnetic fields et cetera have great implications on their health. This means that the physical environment of an individual greatly determines whether he lives a healthy or unhealthy life.
The above mentioned are just but part of the socioeconomic factors that implicate on the health of an individual. Equally, these factors have a role in determining the inequalities experienced in oral. However, the study of these determinants’ effects on oral health has been very limited. Newton and Bower (2005) argue that this is attributed to lack of a theoretical framework that puts into consideration the social processes and how their role within the causal pathways that lead to oral health complications. However, their study points out that there is a strong interlinking relationship between the causal pathways and the society’s structure. This is facilitated by the psychosocial and the other behavioral characteristics of the individuals within the society. This position is further echoed by Sisson (2007) who posits that controlling social inequalities within oral health has become a great challenge because of limited understanding by the practitioners. According to her, social health determinants must be given first hand priority and consideration for any substantial achievement in this endeavor. Considering these suppositions by Newton and Bower, it is important to specifically identify the socioeconomic and cultural dimensions of the society and how these factors contribute to inequalities in oral health. The following section of this paper will identify the each of these effects, one after the other.
Oral health determinants
As mentioned above, lifestyle plays a very important role in determining the health wellbeing of an individual. Equally, this applies to the status of an individual’s oral health (Sisson 2007). Different lifestyles as portrayed by different socioeconomic regions greatly determine the wellbeing of the societies’ oral health. The activities engaged in within a lifestyle can either expose a society to poor oral health or the other way round. In most studies, poor diet and involvement in certain activities like drug and alcohol abuse increases the risk of bad health to an individual. Smoking has also been identified as a lifestyle practice that risks an individual’s life.
One conspicuous case of oral complications resulting from such cases is oral cancer whose prevalence has widely been felt in Asia. According to Petersen (2003), approximately 0.7 out of every 100,000 people in China were affected by oral cancer. This rate increases to 4.6 per 100,000 people in Thailand while India’s rate stands at 12.6 people per 100,000. The World Health organization report shows that these high prevalence rates are attributed to cultural behavior and lifestyles of smoking, chewing miang and betel nut and other smokeless tobacco products and alcohol consumption (Armfield 2007).
Some East African and Arab Peninsular countries have experienced high prevalence of oral mucosal lesions, teeth discoloration, periodontal disease and drying of the mouth. According to World Health Organization, these diseases have high prevalence in East Africa and Arabian Peninsular due to their lifestyle of use of Khat. This is a form of narcotic substance that that is ingested in many ways including smoking like cigarette, drinking in liquid form or by chewing of fresh leaves. This lifestyle has been attributed to the mentioned oral conditions. This points out that Sisson’s and European Union’s arguments that lifestyle can have adverse effects on the health of an individual are realistic. To sum up the role of lifestyle on the development of oral diseases, the World Health Organization report shows that NCDs develop highly in relation to the dietary habits. Consequently, these diseases contribute to the development of dental caries. In addition, the report points out that 90% of oral cavity cancer is attributed to tobacco. Furthermore, tobacco is also attributed to losing of teeth prematurely, periodontal breakdown and general poor hygiene (Freire 2001).
Socio-cultural challenges also contribute to the prevalence of certain oral complications within regions. In Africa for instance, most cultures do not identify oral health as an important part of health. As a result, they do not seek for any medical attention in issues concerning their oral health. In fact, they persevere with these pains and sometimes have their teeth removed to ease the pain and discomfort associated with these oral diseases. Consequently, many of them become victims of oral diseases that could have been easily cured (Sanders 2007). Furthermore, poverty in these regions has resulted into poor nutrition that is associated with certain oral diseases like oro-facial defects. Apart from nutrition, this disease has also been found to be caused by tobacco and alcohol consumption from the mother. Unfortunately, these diseases have been found to be very prevalent in many developing countries. Specifically, the rate of births that experience these complications has been approximated at 1 out of every 500.
Dental caries affects a large percentage of school going children in industrialized and developing countries. The World Health Organization report on oral health points out that an approximated 90% of school children are affected by this disease (WHO 2003). In addition, the London Health Observatory also shows the seriousness of this disease in their report on a survey carried out in London. In this survey, it was found out that approximately 57% of London adults had one or more decayed tooth. Similarly, the rate varied within the localities with low income regions identifying with the highest rate while the most affluent regions exhibiting low rates of prevalence. To be precise, the low income regions accounted for an average of 69% adults suffering from dental caries while the most affluent region accounted for the lowest average of 47%. The disease is especially prevalent in America where the World Health Organization report attributes this prevalence to lifestyle. This includes smoking and excessive consumption of sugary foods. The rate is however lowest in Africa and Asia. With the changing eating habits in Africa, the rate is expected to go higher even in Africa. The increase in consumption of sugary foods means that more people will be affected by dental caries. In addition, the limited exposure to fluorides might also catapult the rate of dental caries within the African population (World Health Organization 2003; Lopez et al 2006).
The London Health Observatory (2009) posit that the socio economic status contribute to a large extent to the disparities and inequalities in oral health within societies. This leads to an identified gradient directly co-relating with the level of within the ladder of the socio economic ladder. This position is also echoed by the World Health Organization who point out that the group of people who suffer greatly from this diseases are those that are disadvantaged and those that are marginalized. The less advantaged people expose themselves to risk factors that eventually increase their chances of getting the diseases. Equally, people with low income lack the monetary ability to purchase fixed private insurance. This forces them to rely on the public dental services have less quality as compared to private facilities. In addition, greater tooth loss is also exhibited by individuals with low education level (Sanders 2007). It is therefore important that policy makers trying to come up with ways of reducing the inequality gap to come up with policies that put these determinants into consideration. This is the most important approach that will enable them achieve not only solutions to cure the diseases but also to control and prevent the healthy population from contracting these diseases.
Strategies to improve oral health inequalities
In 1979, the World Health Organization came up with the goal aimed at ensuring that dental caries global average never exceeded 3 DMFT (decayed, missing, and filled teeth) at twelve years of age. However, the goal has never been well achieved. By the year 2000, not every country had achieved the World Health Organization goals. In fact, only 68% of the 183 countries whose data was available had achieved the goal. The remaining percentage could not meet the target. What, therefore, could be done to achieve these targets? Are there ways through which policy makers could make viable strategies that could facilitate their endeavor to attain the World Health Organization goals? This part of the paper will examine strategies with which the policy makers can adopt in order to experience reduction in the inequalities in oral health (World Health Organization 2003; Rahmatulla and Wyne 1993).
The previous parts of this paper have shown that oral health determinants are a fundamental part for consideration when combating oral diseases and complications. It is therefore a prerequisite that before any strategy is made to reduce the inequality in oral health, the society’s socio economic and cultural factors are put into consideration. Considering that curative measures are also important when combating any disease, this paper aims to point out that a good strategy should be holistic. It should put into consideration both the determinants and the curative measures. When considering the determinants, it is essential that all dimensions of social and economic factors are incorporated. Apart from considering each demographic bracket uniquely, the strategy should also consider physical or environmental risk factors, the socio-cultural risk factors and the health system, specifically oral health service providers properly.
To begin with, a good strategy must involve the government and other policy makers within its activities. A good strategy gives the dental teams a pivotal role in combating inequalities in oral health. This is important because through the involvement of dental teams within each locality, their involvement in primary health ensures that tailor made solutions to address the each specific locality are developed. Involving the dental teams is the first and major step however, this involvement should also incorporate all the other health care service providers in order to ensure that patients receive a holistic health care which will not only put their oral health into consideration, but also the other diseases that together contribute to the escalation of oral diseases cases (British Dental Association 2005). To facilitate their activities, the government should also be included in the strategy. The most appropriate way that the government can involved is through the provision of funds to facilitate the dental teams’ activities and initiatives.
A good strategy should also put into consideration the knowledge of the people towards oral health. Curative measures are good strategies in disease control but preventive measures are better. However, to achieve positive results in prevention of a disease, it is necessary that the people are engaged in their health through discussions and other educative measures. The British Dental Association argues that engaging people in their health, diseases will be controlled as opposed to curative measures. Dental teams should take it as their responsibility to ensure that people are armed with appropriate knowledge so that with this, their decisions on oral health can be informed and founded. Dental information should be propagated even to the population segments whose accessibility is ranked difficult. The education given to the public should include information on the implications of their behavior on their general health. The oral health service providers should also ensure that the general public is informed on the proper ways of cleaning their mouth. Furthermore, the education should not be structured generically; it should be culture specific and hence address culture specific problems (Sabah et al 2007).
A good strategy should also involve multi agency role playing. As mentioned earlier, oral health is not a problem of the society that stands on its own. For an effective control and preventive strategy, all relevant agencies should work together so that an all inclusive solution is arrived at. For instance, the strategy should involve local authorities, private organizations and the health sector. These different role players will ensure that the society’s different problems are addressed fully. For instance, if a private organization is involved in the promotion of healthy teeth, the campaign team should include a professional from the health sector. The initiatives by the private organizations could rely on the expertise from the professional. At the same time, the local authorities have to fund the initiatives. This interrelated role facilitates the effectiveness of the strategy.
Next, the strategy should not generalize the demographic classes of the society. For instance, children and disabled adults’ requirements might exceed the normal adult population. Without doubt, these two groups might need more support and actions. Therefore, professional training and thorough research should be incorporated within the strategy. In addition, the strategy should have specific provisions that address the needs for the elderly within the society. Therefore, any member of the society with special needs must be attended to by a specialist.
On the other part, the socio cultural factors which form the health determinants should be well addressed in the strategy. One of the initiatives that must be incorporated within the strategy must involve the best practice that will promote good diet and nutrition. This is especially very important in the field of oral health. As identified earlier, there are several oral diseases that result from poor nutrition. For instance, the study by World Health Organization showed that while Africa showed the least prevalence in the case of dental caries, the future might witness a difference. This is attributed to the fact that the changing diet is exposing more Africans to sugary foods while very few of them are exposed to fluoride. This means that a good strategy must include an initiative by which the society’s diet can be addressed (Antunes et al 2004).
Conclusion
Health inequalities have been witnessed in different sections of the society. Despite the improvement of health provision in the last few decades, many developing countries still witness low instances of good health. Studies have shown direct correlation between the economic status of an individual and health. The European Commission, Sanders, World Health Organization, et cetera all point out that the graph of an individual’s health relates directly to his position on the social ladder. This means that certain factors within the social set up contribute to oral health. This led to Marmot and Wilkinson’s development of health determinants. Like any other form of health, oral health depends entirely on the determinants.
To begin with, the culture of a society could influence its oral health. Cultural practices, beliefs and lifestyle can determine one’s health. A good example is the prevalence of oral cancer in East Africa and Arabian Peninsular all attributed to the consumption of khat, a narcotic substance grown in the region. Equally, China and some parts of Asia have been identified to possess high prevalence of some oral diseases attributed to excessive consumption of alcohol. Therefore, the cultural practices and beliefs can determine an individual’s oral health. Furthermore, tobacco and other substances have been identified to be among the greatest determinants of oral health. In most developed countries, dental caries affects many people and all this is attributed to their consumption of tobacco and alcohol.
What, therefore, can be done to ensure that inequalities in oral health within a society are minimized? A good strategy must involve three main aspects. To begin with, it must involve a well structured health care system, initiatives to address the oral health determinants and initiatives to address the physical factors that increase the risk of contracting the given disease. The strategy must ensure that dental teams educate the public on ways through which they can improve their oral health. Still, the dental teams should ensure that they work in coordination with other sectors like the private organizations and the civil authorities. The role of the private sectors is to provide the strategies with assistance from a professional from the health sector. On their part, the local authorities must ensure that they provide funding that will facilitate the initiatives from the private organizations. Also, a good strategy must put into consideration the various classes within a society’s demography. It should include special programs for special groups of people that need more support. These groups include the mentally handicapped, the children, the elderly and others. The strategy should ensure that the special needs of these people are catered for. Finally, a good strategy realizes that prevention and control of oral diseases does not rely entirely on oral health. It depends upon several other factors of health. As a result, it is important that a good strategy incorporates other agencies. Reducing inequalities in the health sectors can only be successful if the strategy involves the whole health sector.
When these strategies are well put into consideration, the inequalities experienced in oral health can be reduced greatly. The burdens associated with the oral diseases can be a thing of the past. Equally, other benefits associated with oral health including longer life expectancy, general health and comfort can be increased within the population. Considering the importance of determinants of oral health in control and prevention of oral diseases, it is important that policy makers come up with strategies that assume a holistic approach. This means that curative measures should be incorporated with socio cultural and economic factors within the strategies. With the employment of a strategy with the above mentioned characteristics, inequalities will be a thing of the past.
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