Action on reducing oral health
inequalities
IAPD, Glasgow
Professor Richard G Watt
Department of Epidemiology & Public Health, UCL
Health inequalities
Key public health challenge for
21st century
HEALTH DIFFERENCES
INEVITABLE
POTENTIALLY AVOIDABLE
ACCEPTABLE
UNACCEPTABLE, UNFAIR
INEQUALITIES
Dahlgren & Whitehead (1991)
Life expectancy at birth (men)
UK, Glasgow (Calton)
54
India
62
US, Washington D.C. (black)
63
Philippines
64
Lithuania
65
Poland
71
Mexico
72
Cuba
75
US
75
UK
77
Japan
79
US, Montgomery County (white)
80
UK, Glasgow (Lenzie N.)
82
Sources: WHO World Health Statistics 2007; Hanlon, Walsh & Whyte 2006; Murray et al. 2006
Oral health inequalities
Distribution of Oral Disorders Globally
(age-standardized, both sexes, DALYs per 100,000)
Source: IHME, Global Burden of Diseases (2013)
Avg. number of decayed (dt), missing (mt), filled (ft), teeth for 5 year old children in Islington 2003/04 by
school. ( Source:BASCD 2004)
Average of dt
Average of mt
4
3.5
3
Avg.dmft
2.5
2
1.5
1
0.5
0
School
Average of ft
Oral health inequalities:
Latest Findings from CDHS 2015
Inequalities: behaviours & impact
• Oral health behaviours varied by
SES eg
– Toothbrushing (72% vs 82%)
– Regular dental attendance (66% vs
86%)
– Sugar drinks (13% vs 26%)
• Significant variation by SES on
subjective impacts of oral disease
eg
– Pain (27% vs 11%)
– Two or more difficulties (39% vs 28%)
Determinants of
health inequalities
Oral health determinants
Bio-medical perspective
– Oral hygiene
– Sugars consumption
– Smoking and alcohol
– Exposure to fluoride
– Use of dental services
Social determinants of
health
The main determinants of health
Complex influences on health
Wider influences
Lifestyle factors
Health
individuals & communities
Implications for health
improvement
What does the evidence
show?
Effective policies to reduce inequalities
Structural changes in environment
Legislative and regulatory controls
Fiscal policies
Starting young
Community action
Improving accessibility of services
Prioritizing disadvantaged population groups
(WHO 2003; Bambra et al., 2010; Lorenc et al., 2012)
Ineffective interventions – increase inequalities
Information based campaigns (mass media
programmes)
Written materials (leaflets and posters)
Campaigns reliant on people taking the initiative
to opt in
Health education campaigns designed for the
whole population
(MacIntyre, 2007; Lorenc et al., 2012)
Inverse prevention law
Even when interventions are successful at
improving health across the population,
they may increase health inequalities.
(Gordon et al., 1999; Lorenc et al., 2012)
Scottish dental health education intervention
Plaque index=0
No bleeding
45
85
40
80
35
30
75
25
20
70
15
10
65
5
0
60
Before
intervention
1 month
after
Non-deprived
4 month
after
Deprived
Before
intervention
1 month
after
Non-deprived
4 month
after
Deprived
(Schou L, Wight C: Does dental health education affect inequalities in dental health? Community Dent
Health 1994, 11(2):97-100.)
Policy Levels for Tackling
Inequalities in Health
Role of clinical dental teams
Understanding needs of local population
Importance of professional training
– Key skills
partnership working
communication;
advocacy;
lobbying
Priority focus on early life – foundations
Ensuring equity of access & outcomes
Developing a team approach – skill mix
Delivering evidence based clinical
prevention – targeted to disease risk
Partnership working with local agencies &
services
Dentists as local employer
– Recruitment & training of local people
– Career development
Supporting wider action through advocacy
& lobbying eg dental associations
Watt et al., 2014
National oral health prevention policies
Dental Public Health
ucl.ac.uk/dph
Public health approach
www.ucl.ac.uk/dph
Upstream - downstream interventions
National &/or local policy initiatives
‘Upstream’
Healthy Public Policy
Legislation/Regulation
Fiscal Measures
Healthy Settings- HPS
Community Development
Training other professional groups
Media Campaigns
School dental
health education
Chair side dental
health education
‘Downstream’
Watt, CDOE (2007)
Health Education &
Clinical Prevention
Clinical Prevention
Conclusions
Global challenge of addressing oral health
inequalities
Need to recognise limitations of biomedical
preventive model
Time to adopt a social determinants approach in
oral health policy
Thank you for your
attention
r.watt@ucl.ac.uk
www.ucl.ac.uk/dph