Social determinants of oral
health disparities
Tracy L. Finlayson, PhD
2015 Southern California State of Reform Health Policy Conference
November 6, 2015
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Oral health is important!
THE PROBLEM….
• Untreated dental diseases are a ‘silent epidemic’
• disproportionately affects individuals of low
socioeconomic status (SES) and racial/ethnic
minorities
– pain, missed school/work, problems chewing/eating,
problems talking, reduced quality of life
» Surgeon General Report on Oral Health, 2000
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Social gradients in health
Reaching for a Healthier Life: Facts on Socioeconomic status (SES) and Health
http://www.macses.ucsf.edu/downloads/reaching_for_a_healthier_life.pdf
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The Problem
“Mommy, It Hurts to Chew” - California Smile Survey
AN ORAL HEALTH ASSESSMENT OF CALIFORNIA’S KINDERGARTEN AND 3RD GRADE CHILDREN (2006)
•
http://www.centerfororalhealth.org/images/lib_PDF/dhf_2006_report.pdf
4
http://www.cdc.gov/nchs/data/databriefs/db104.htm#x2013;2010</a>
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Periodontal Diseases
Recent CDC report of periodontitis prevalence in the U.S.:
• Almost half (47.2%) of adults 30 years and older have
some form of periodontal disease.
• Periodontal Disease increases with age, 70.1% of adults
65 years and older have periodontal disease.
• more common in men than women (56.4% vs 38.4%),
those living below the federal poverty level (65.4%),
those with less than a high school education (66.9%),
and current smokers (64.2%)
• http://www.cdc.gov/oralhealth/periodontal_disease/index.htm
• Eke PI, Dye B, Wei L, Thornton-Evans G, Genco R. J Dent Res. 2012
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Dental diseases are PREVENTABLE
so what should we do?
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Framework to conceptualize and act upon eliminating the sources of oral health disparities
Copyright © by International & American Associations for Dental
Research
SoCal
State of
J.Y. Lee, and K. Divaris J DENT RES 2013;93:224-230
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National oral health indicators and
policy goals
Healthy People 2020 Leading Health Indicator (LHI)
http://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Oral-Health
OH-7: Increase the proportion of children, adolescents, and adults who used the oral
health care system in the past year
HP2020 RESOURCE LIST ON SOCIAL DETERMINANTS:
http://www.healthypeople.gov./2020/topics-objectives/topic/social-determinantshealth/addressing-determinants
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A systems change
framework
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DentaQuest Foundation’s Proposed
Oral Health 2020 Goals
http://dentaquestfoundation.org/oh2020
Oral Health 2020 investments and network building strategies
are structured around the realization of a shared vision by the year 2020:
"Oral health is essential to lifelong health and well-being."
• Goal 1 Eradicate dental disease in children.
• Goal 2 Incorporate oral health into the primary education system.
• Goal 3 Include an adult dental benefit in publicly funded health
coverage.
• Goal 4 Build a comprehensive national oral health measurement
system
• Goal 5 Integrate oral health into person-centered healthcare.
• Goal 6 Improve the public perception of the value of oral health to
overall health.
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Access
• Dental services often separate in our
healthcare system
• Dental is an essential health benefit for
children under ACA.
• Medicaid adult dental benefits are OPTIONAL
• CA dropped Medicaid adult dental benefits
from 2009-2014
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Denti-Cal Reports & select references
• http://www.denti-cal.ca.gov/WSI/Default.jsp?fname=Default
• Denti-Cal Denied: Consumers’ Experiences Accessing Dental Services in
California’s Medi-Cal Program, 2002.
http://www.healthconsumer.org/DentiCalRpt.pdf
• California HealthCare Foundation, Denti-Cal Facts and Figures (Oakland,
CA: California HealthCare Foundation, 2007).
• CDA - http://www.cda.org/news-events/basic-denti-cal-services-foradults-to-be-re-established-may-1
• Wides et al 2014 Shaking up the dental safety-net: Elimination of optional
adult dental Medicaid benefits in CA. JHCPU 25: 151-164.
• Decker, S.L. and B.J. Lipton. 2015. DO MEDICAID BENEFIT EXPANSIONS
HAVE TEETH? THE EFFECT OF MEDICAID ADULT DENTAL COVERAGE ON
THE USE OF DENTAL SERVICES AND ORAL HEALTH. Journal of Health
Economics.
• Singhal, A., et al., Eliminating Medicaid Adult Dental Coverage In California
Led To Increased Dental Emergency Visits And Associated Costs. Health
Affairs, 2015. 34(5): 749-756.
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Select CA dental policies
• Kindergarten Oral Health Requirement
– AB 1433
– Requires dental check-up (or parent waiver) by
May 31 for all children starting Kindergarten in
public schools each fall
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Virtual Dental Home
AB 1174
• ww.virtualdentalhome.org
• community-based oral health delivery system in which
people receive dental diagnostic, preventive and early
intervention services in community settings.
• Uses telehealth technology to link allied dental
professionals in the community with dentists in dental
offices and clinics, facilitating access to the full dental
team and comprehensive dental care.
» http://dental.pacific.edu/Documents/community/special
_care/acrobat/Pacific_VDH_FactSheet_2015_0903.pdf
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Older Americans Act
• U.S. Senate amended the Older Americans Act to
include Oral Health as a critical service for Older
Adults
• This amendment will open the door for state and
area agencies on aging to use funds to improve the
oral health of older adults
– http://www.centerfororalhealth.org/images/lib_PDF/CenterforOral
HealthPressReleaseUSSenateOlderAdults.pdf
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CA leadership and coalition
• New CA state Dental Director, appointed earlier
this year - Dr. Jaynath V. Kumar, DDS, MPH
• Oral Health Action California http://oralhealthcalifornia.org/
• Center for Oral Health http://www.centerfororalhealth.org/
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Grassroots community efforts
“Health starts in our homes, schools and
communities”
“Health begins where we live, learn, work and
play.” – RWJF 2010
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Healthy Mouth, Healthy Body
The mouth is connected to the body!
Community-based participatory research (CBPR) project
The study aimed to use a CBPR approach to:
- improve low oral health literacy and
- reduce dental care access barriers
among North San Diego County’s migrant
families in three target communities
More info at http://www.sdprc.net/research/other-projects/boca-sana-cuerpo-sanohealthy-mouth-healthy-body/
Study Funded (2012-2015) by:
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Mexican migrant families North San Diego County
- Family
focused
education
led by
CHW
- Lideres
advocacy
network
SDSU
Mexico
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Lessons from BSCS Oral Health
Intervention
Community input in design
and content
- family focused
- priority topics
Addressing poverty
Provide services
Rights as a patient
Advocacy efforts
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Community Health
Worker (CHW) Model
Fluoride Varnish (FV)
• CHWs can be trained to apply FV in PH
programs under CA law AB 667
• BSCS photos 2014-5
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KEY MESSAGES
Reducing oral health disparities will require
• Moving upstream from the individual
• Addressing psychosocial & societal level health
determinants
• Creating healthy communities - where people live,
work and play
• Bringing unheard community voices to the table, and
building effective community-based partnerships
• Getting out of silos and creating inter-disciplinary and
multi-disciplinary teams together for research to create
a strong evidence base for changing policy and practice
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Infographic - http://www.beckyhirstconsulting.com.au/offline/healthy-communities-create-healthy-people/
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Thanks for your time and attention!
Tracy L. Finlayson, PhD
Email: tfinlays@mail.sdsu.edu
Associate Professor
Director, Graduate Program in Health Management & Policy
Graduate School of Public Health
San Diego State University
http://publichealth.sdsu.edu/
Core Investigator, Institute for Behavioral
& Community Health
http://www.ibachsd.org
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Extra Slides
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Brief Biography
Tracy L. Finlayson, PhD, is an Associate Professor and Director of the Graduate
Program in Health Management and Policy at the San Diego State University (SDSU)
Graduate School of Public Health. She teaches courses on the US health system and
Health Policy.
She is an interdisciplinary health services researcher with training in Sociology/Social
Psychology. Her research program explores the psychosocial determinants of oral
health disparities, and access to dental care, particularly for vulnerable populations.
Her research often integrates quantitative and qualitative approaches. Dr. Finlayson
has been involved in evaluations of major state-level policy changes in Michigan and
California. In 2008, Dr. Finlayson received the Jay S. Drotman Memorial Award from
the American Public Health Association (APHA).
•
•
•
http://www.researchgate.net/profile/Tracy_Finlayson
http://publichealth.sdsu.edu/people/current-faculty/tracy-finlayson/
Current affiliations: http://www.ibachsd.org/ and http://www.cando.ucsf.edu/
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Select social determinants and oral
health references & resources
• Krieger, N. Embodiment: a conceptual glossary for epidemiology. J
Epidemiol Community Health 2005;59:350-355
• Lee, J.Y. and K. Divaris, The ethical imperative of addressing oral health
disparities: A unifying framework. J Dent Res, 2014. 93(3): p. 224-230.
• Link BG, Phelan J. Social conditions as fundamental causes of disease.
Journal of Health and Social Behavior 1995; 35(extra issue):80-94.
• Newton JT, Bower EJ. The social determinants of oral health - New
approaches to conceptualizing and researching complex causal networks.
Community Dent Oral Epidemiol 2005; 33:25-33.
• Sheiham A, Watt RG. The common risk factor approach: a rational basis for
promoting oral health. Community Dent Oral Epidemiol 2000; 28:399-406.
• Surgeon General Report, Oral Health in America. 2000
• Watt RG. Social determinants of oral health inequalities: implications for
action. Community Dent Oral Epidemiol 2012; 40 Suppl 2:44-8.
• World Health Organization. The Ottawa Charter for Health Promotion.
Health Promotion 1. i-v. Geneva: WHO; 1986
• http://www.who.int/social_determinants/en/
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Other Figures/models
• Patrick, D., et al., Reducing oral health
disparities: A focus on social and cultural
determinants. BMC Oral Health, 2006. 6
(Suppl 1): p. S4.
• Fisher-Owens, S.A., et al., Influences on
Children's Oral Health: A Conceptual Model.
Pediatrics, 2007. 120(3): p. e510-520.
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Patrick et al. BMC Oral Health 2006
Fisher-Owens, et al,
2007, Pediatrics,
120(3), e510.
http://pediatrics.aappubli
cations.org/cgi/content/f
ull/120/3/e510
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Trained community health workers / leaders
Lideres Communitarios
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5- week low literacy health CHW education materials – English & Spanish
colorful, visual, hands-on activities, supplies to take home, weekly goals
Class #1: Tooth decay & bacteria process
Class #2: Oral hygiene
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Class #3: Nutrition
Class #4: Periodontal disease
Class #5: Dental Treatments
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More oral health resources
• Smiles for life - free national curriculum to
ensure the integration of oral health and
primary care. (3rd ed – 8 modules)
• http://www.smilesforlifeoralhealth.com
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Common Risk Factor Approach
Major common risk factors for chronic diseases:
– Smoking
– Poor diet (lot sat. fats/sugar, few fruit/veg/fibre)
– Stress and low control
– High alcohol consumption
– Poor hygiene
– Injuries
– Sedentary lifestyle
• Develop broad policies with all these common risk factors
in mind – more holistic approach and more integrated with
other health promotion efforts
– Example: food policy
Source: Sheiham & Watt, 2000
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Common Risk Factor
Approach (CRFA)
CHWs at food distributions
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Social factors and processes to explore
further for promoting oral health
• Social networks and supports, social capital
• Effects of discrimination
• Psychosocial factors- control, efficacy
• Stress and coping resources
• Role of religiosity/spirituality
• Family, housing, neighborhood, and community
characteristics
• How social determinants vary by generation and
over the life course
• Effects on quality of life
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