doi:10.1038/nindia.2017.22 Published online 16 March 2017
• 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.
‘‘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.
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.
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(firstname.lastname@example.org).
2. Arcaya, M. C. et al. Inequalities in health: definitions, concepts, and theories. Global health Action. 8, 27106 (2015)
3. Starfield, B. Are social determinants of health the same as societal determinants of health? Health Promot. J. Austr. 17, 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 Serv. 40, 215-221 (2010)
6. Labonte, R. et al. The trans-Pacific partnership agreement and health: few gains, some losses, many risks. Global. Health. 12, 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. Health. 11, 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 Health. 61, 473-478 (2007)