Special Feature

doi:10.1038/nindia.2017.22 Published online 16 March 2017

Societal determinants of oral health inequalities in Asia–Pacific

[Nature India Special Issue: Oral Health Inequalities and Health Systems in Asia-Pacific]

Ankur Singh1


Policy Recommendations

• Policies to address oral health inequalities should identify underlying societal determinants.

• Surveillance and monitoring of oral health inequalities should be strengthened.

• Policy interventions should be based on plausible social and biological mechanisms. 


Ankur Singh

‘‘If your only tool is a hammer, all your problems will be nails.’’ — Mark Twain

Health inequalities are the systematic, avoidable, unjust and unfair dif­ferences in health status in populations according to social, ethnic and geographic groups1. Differences in oral health status according to an individual’s social position and status reflect inequalities at the individual level within a population. Differences in average oral health status between popu­lation groups reflects oral health inequalities at the population level2. Thus, oral health inequalities can be conceptualized both at the individual and pop­ulation level.

The Asia-Pacific region comprises a diverse mix of countries in terms of economic development, socio-cultural diversity, power balance in global governance and trade relations, free market operations, geographical size, population density and political ideologies. This diversity across different so­cial, political and geographic dimensions must be observed, especially when identifying policy solutions to address oral health inequalities. Ignoring this diversity may bring a false conclusion that a basic set of policy solutions may address oral health inequalities at the individual and population level, and in all contexts.

Characteristics that form the social and physical environments in which people live and work, and determine distributions of population health, are recognized as the societal determinants of health3, and several theoretical models (or explanations) exist to describe them. Galea4 provided a frame­work summarizing different characteristics relevant to population health at the global, national and community levels. At the global level these include global trade, income distribution, population movement, global governance, and communications and technology. At the national level, these include infra­structural resources, employment decisions, income growth, population den­sity, governance/policies. Correspondingly, at the community level these are resource allocation, social services, physical environment, social environment and population heterogeneity.

Theoretical models are also specifically proposed to identify societal de­terminants pertinent to addressing health inequalities3, 5.  According to Mun­taner, Chung5 macro-level societal factors; including power relations between markets, government and civil societies; policies around labour market and welfare state, relationships between employment conditions, material depri­vation, economic inequalities and health systems interact at different hierar­chical levels to determine the degree of inequalities.  Likewise, another theo­retical model places ultimate importance on political context which, through its diffused effects on public health policies, influences multiple factors closely related to distribution of health3. These factors include distribution and levels of income, power relationships, behaviours, cultural characteristics and health system characteristics3. Evidence to assess the role of these determinants in the distribution of population oral health is scant compared to evidence avail­able on general health both in the region, and globally.

Policy solutions to address oral health inequalities which do not account for underlying societal determinants can fail to achieve objectives, despite having correct intentions. Considering the diversity in societal and demo­graphic differences within Asia-Pacific, tailoring policy solutions will require a better understanding of the contextual characteristics. This makes the need to understand ‘societal determinants of health’ a vital first step towards reducing oral health inequalities.

Debate around the trans Pacific partnership agreement

A current debate around the public health implications of the Trans Pacific Partnership (TPP) agreement involves several countries within the Asia-Pacif­ic region including Singapore, Brunei, New Zealand, Australia, Vietnam, Ma­laysia and Japan. Some of the implications raised include intellectual property rights driving the prices of pharmaceuticals, food standards policies impacting food safety, investor state dispute settlements, which can delay implementa­tion of protective policies, such as plain packaging and sugar tax (regulatory chill), and precarious employment conditions6. None of these issues are ex­clusive to general health outcomes, and are very likely to impact levels and distribution of oral diseases within societies at multiple levels.

Recent reports from Vietnam show an increase in overall intake of sug­ar sweetened beverages, a known risk factor for dental caries, after remov­al of trade regulations in Vietnam7. Under such macro-level socioeconomic changes, disadvantaged individuals are more vulnerable due to the lack of knowledge, money, power, prestige, and beneficial social connections8. Subse­quently, the oral health inequalities at the individual level within countries may further escalate. In light of achieving economic goals, and negotiating power held by countries in global market, changes to protective public and public health policies can highly impact oral disease levels and its distributions. Therefore, understanding societal determinants of oral health inequalities is of fundamental importance.

The way forward 

Margaret Whitehead, a pioneer in health inequalities research summed up the issue of policy solutions for health inequalities9

The first step to address oral health inequalities within the Asia-Pacific region demands an understanding of the societal determinants that shape the distribution of oral health within and between countries. Surveillance and monitoring of oral health inequalities according to contextually relevant so­cial groups2 will provide reliable evidence for creating evidence based policy solutions.

Different categories of policy solutions to address health inequalities in­clude; strengthening individuals, strengthening communities, improving living and working conditions, and promoting healthy macro policies. Of these, the latter is most likely to have diffused effects and benefits, but depending on the context and problem, different combinations with other categories may be indicated9. Overall, there is a need to better understand the problems that escalate oral health inequalities within and between countries in the region, to reach out for most effective policies.


1Research Scholar, Australian Research Centre for Population Oral Health, Adelaide Dental School, the University of Adelaide, Australia SA 5005(ankur.singh@adelaide.edu.au).


References

1. Whitehead, M. & Dahlgren, G. What can be done about inequalities in health? Lancet. 338, 1059-1063 (1991)

2. Arcaya, M. C. et al. Inequalities in health: definitions, concepts, and theories. Global health Action8, 27106 (2015)

3. Starfield, B. Are social determinants of health the same as societal determinants of health? Health Promot. J. Austr17, 170-173 (2006)

4. Galea, S. Macrosocial Determinants of Population Health. Dordrecht: Springer (2007)

5. Muntaner, C. et al. A Macro-Level Model of Employment Relations and Health Inequal­ities. Internat. J. Health Serv40, 215-221 (2010)

6. Labonte, R. et al. The trans-Pacific partnership agreement and health: few gains, some losses, many risks. Global. Health12, 25 (2016)

7. Schram, A. et al. The role of trade and investment liberalization in the sugar-sweet­ened carbonated beverages market: a natural experiment contrasting Vietnam and the Philippines. Global. Health11, 41 (2015)

8. Phelan, J. C. et al. Social conditions as fundamental causes of health inequalities: The­ory, evidence, and policy implications. J. Health Soc. Behav. 51, S28-S40 (2010)

9. Whitehead, M. A typology of actions to tackle social inequalities in health. J. Epidemi­ol.Community Health61, 473-478 (2007)