|Year : 2014 | Volume
| Issue : 4 | Page : 258-263
Health disparity with light on oral health inequality - A review
Bennadi Darshana1, Kshetrimayum Nandita2
1 Department of Public Health Dentistry, Sri Siddhartha Dental College and Hospital, Tumkur, Karnataka, India
2 Department of Public Health Dentistry, Regional Institute of Medical Sciences, Dental College, Lamphelpat, Imphal, West Manipur, India
|Date of Web Publication||20-Nov-2014|
Department of Public Health Dentistry,Sri Siddhartha Dental College and Hospital, Agalkote, Tumkur 572 107, Karnataka
Source of Support: None, Conflict of Interest: None
A health disparity (HD) is one of the major public health challenges. The "Healthy People 2020" have got many objectives which includes having access to preventive dental services. Another important activity of "Healthy People 2020" is to monitor health disparities. Oral health is essential to the general health and well-being of individuals as well as for the entire population. Disparities in health among income, racial and ethnic groups are significant. The most powerful factors shaping both health and health disparities are social and economic determinants, or the community conditions for health.  This paper reviews health disparity with light on oral health inequalities and its prevention.
Keywords: Ethnicity, health disparities, oral health inequalities, race, socioeconomic status
|How to cite this article:|
Darshana B, Nandita K. Health disparity with light on oral health inequality - A review. SRM J Res Dent Sci 2014;5:258-63
| Introduction|| |
''A person's life journey from womb to tomb is nested in human societal substructures which has a biological endowment-genetic-intrauterine, epigenetic-contributing with physical, social, chemical, and environmental exposures interacting tightly over a whole lifetime to give health outcomes-trauma, disease, disability. We may not be able to do much to change the genes, but we can change the environment.'' John Frank. 
Now a days, people are facing many challenges related to health like Acute and Chronic conditions, Aging population, Health Disparities, Emerging Diseases and Biodefense. ,
A population is a health disparity population, if there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status of the general population. Minority Health and Health Disparities Research and Education Act of 2000. ,
According to Dressler and colleagues, HD determined by use of Racial genetic model, Health behaviour model, Socioeconomic and Psychosocial stress model. 
Health disparity can occur at individual level or health care level and it is caused by 
- At an individual level- Socioeconomic and Environmental characteristics, different ethnic and racial groups.
- From the barriers- certain racial and ethnic groups encounter when trying to enter into the health care delivery system. The common reasons for Health disparity in access to health care are ,
- Lack of a regular source of care
- Lack of financial resources
- Legal barriers
- Structural barriers
- Linguistic barriers
- The health care financing system
- Scarcity of providers
- Health literacy
- Lack of diversity in the health care workforce
- Biological factors such as age
- Lack of Insurance coverage
3. From the quality of health care- different ethnic and racial groups receive.
Problems with patient-provider communication: Communication is critical for the delivery of appropriate and effective treatment and care, regardless of a patient's race. Miscommunication can lead to incorrect diagnosis, improper use of medications, and failure to receive follow-up care. Example, patient health decisions can be influenced by religious beliefs, mistrust of Western medicine, and familial and hierarchical roles. 
Provider discrimination: Health care providers either unconsciously or consciously treat certain racial and ethnic patients differently than other patients. Some researchers argue that certain diseases cluster by ethnicity and that clinical decision making does not always reflect these differences. 
Social determinants matter for health outcomes
Social determinants 
Social and cultural conditions such as cultural beliefs and attitudes, and legal channels can be altered by programs and policies. These social determinants interact with biological and personal determinants at a collective level to shape individual biology, individual risk behaviors, environmental exposures, and access to resources that promote health. A graded relationship between social position and health status affects all persons in the social hierarchy. ,
Through the process of social stratification, individuals are divided into subgroups. They are differentiated based on attributes that are considered important by society, such as income, race, sex, and education. Once the process of differentiation has occurred, individuals are evaluated based on their attributes. Individuals with more favorable attributes are sorted into a higher social status in the hierarchy, which subsequently determines the provision of rewards. This social hierarchy provides differential benefits to individuals who occupy different positions. Hence, stratification functions as a process that formalizes inequality in the form of unequal access to valuable resources, such as quality housing, education, health care, and dental care. Thus, low-income groups, racial minorities, and people with disabilities are often found to have higher hospitalization rates and more emergency room visits than people of higher income, often due to the unhealthy and unsafe environments in which they live. , Health disparities reflect differences in health because of sociodemographic variables, such as race, socioeconomic status (SES), and gender. ,
Race and ethnicity
These are major determinants of socioeconomic position. After adjusting for SES, racial differences persist in the quality of education, the family wealth associated with a given level of income, the purchasing power of income, the stability of employment, and the health risks associated with occupational status. To improve medical treatment and prevent and reduce health disparities, efforts have focused on diversifying the healthcare work force to better reflect the diversity of patients and to improve cultural sensitivity and competence. "Though it is well known that racial and ethnic differences reflect socioeconomic differences and inadequate health care, contemporary evidence suggests that racial, ethnic, class, and gender bias along with direct and indirect discrimination are also important factors." ,
Socio-economic status (SES)
SES remains perhaps the most powerful force producing health disparities - it is massive, multi-factorial, and complex. Low-SES individuals consistently have poorer health across a variety of morbidity and mortality outcomes.  "Studies show that health status improves at each step up the income and social hierarchy" Health Canada. 
SES and race are closely intertwined, with members of many minority groups, on average, being lower in SES. , Thus, some researchers have argued that testing should be done for interaction effects between race and SES. ,,, Race and SES could interact synergistically to affect health. That is, the effects of low SES could be particularly pronounced among minority groups, perhaps if poverty effects are compounded by racism. , The notion that individuals who belong to multiple groups facing discrimination are the most disadvantaged has been termed the double jeopardy hypothesis. ,,
Alternatively, the effects of low SES could be more pronounced among groups that are native born. This might occur because immigrants are more likely to have better health than those in the native-born population, even if they are lower in SES, a phenomenon termed the healthy immigrant effect. ,
The impacts of acculturation on oral health receive attention only in recent years.  The association of acculturation and oral diseases evaluated in many studies have shown high prevalence of dental caries  and periodontal diseases.  Even though studies reported the utilization of dental services, the immigrants have shown poor oral health status and oral health related knowledge. This might be because of use of their cultural norms and beliefs. 
Use of indigenous tobacco and areca products, which are proven carcinogenic, is common in some South Asian countries such as India and Bangladesh. This has led to a high oral cancer rate in these ethnic groups.  Observations on the immigrants' use of these carcinogic products and their oral cancer prevalence along the acculturation process will provide important reference for formulating timely and effective interventions.
Role of gender
Gender discrimination at each stage of the female life cycle contributes to health disparity, sex selective abortions, neglect of girl children, reproductive mortality, and poor access to health care for girls and women. The violation of fundamental human rights, research and especially reproductive rights of women plays an important part in perpetuating gender inequity. Policy makers, programme managers, health professionals, and human rights workers in South Asia need to be aware of and responsive to the detrimental health effects that gender plays throughout the life cycle. 
Urban and rural health disparities 
Some of the common factors like, Transportation, Lack of physicians, Lack of services, Limited services, Insurance, Income and education has created disparity between urban and rural population.
Even National Healthcare Disparities Reported in 2006 that health disparity is one of the most prevalent public health challenge across all the dimensions of health and health care systems like Quality of health care, Access to care, Types of care, Clinical conditions of disease, Care settings including: Primary care, home health care, emergency departments, hospitals, and nursing homes. 
Inequalities in oral health
Reducing inequalities in health has become a major focus for government health policy. Oral health inequalities will only be reduced through the implementation of effective and appropriate oral health promotion policy.  [Table 1] shows inequalities in oral health diseases. ,
Inequalities in health present within the individual, community, society itself. So this can be tackled by Strengthening individuals and communities, improving access to essential facilities and encouraging economic and cultural change. This will only be reduced through the implementation of these effectives and appropriate health promotion policies. These policies should be developed on principles like, utilize multisector and multistrategy approaches, tailor community-driven interventions to the specific community context, understand and address the role of race and ethnicity in building healthy communities and strengthen and build upon community assets for the long term. ,,
The Commonwealth Fund, in a report on how to eliminate health disparities, says that the following steps should be considered in developing policies to eliminate racial and ethnic disparities: ,
- Consistent racial and ethnic data collection by health care providers.
- Effective evaluation of disparities-reduction programs.
- Minimum standards for culturally and linguistically competent health services.
- Greater minority representation within the health care workforce.
- Establishment or enhancement of government offices of minority health.
- Expanded access to services for all ethnic and racial groups.
- Involvement of all health system representatives in minority health improvement efforts.
Some of Local and Regional Projects are working to tackle health disparity and improve their health at national and international level like. 
Healthy black family project ,,
The Healthy Black Family Project (HBFP) concentrates on several East End neighborhoods of Pittsburgh. HBFP works with individuals and families, providing a variety of activities and services to prevent diabetes and hypertension, through health coaches, lay health advocates, and nutritionists at no cost to help families alter their activity and diet to create and maintain a healthy lifestyle.
Take a health professional to the people 
It is just the sort of innovative solution needed to address this serious disparity problem. Part of the Health Advocates In Reach (HAIR) program sends doctors, nurse, pharmacists and health educators into the barber shops and beauty salons of underserved communities to deliver health screenings and health education in a familiar, comfortable environment. By focusing efforts on a single day they believe they can help generate a greater understanding of the importance of regular health screenings while at the same time reaching people who have the least access to healthcare.
Health disparity working groups ,
These groups are associated with planning and organizing health promotion activities and implemented during National Minority Health Month (NMHM), which occurs every April. These NMHM community-based events and activities are deeply rooted in the history of the Black community.
Academy for health equity ,
This organization can bring together all the diverse stakeholders to exchange ideas, disseminate information, and engage in research and training in a coordinated effort to promote health equity for all populations.
Minority health archive
It is a free service, providing research opportunities and an online reservoir for collecting any important information relevant to the health of minorities. ,
Disparities leadership program 
This addresses the need for leaders with expertise in addressing racial/ethnic disparities in health care and designed for leaders from hospitals, health plans and other health care organizations.
Research: EXPORT health
The Centre for Excellence EXPORT Health was established within the Centre for Minority Health in 2002, with six million dollar grant from the National Institutes of Health (NIH), National Centre for Minority Health and Health Disparities (NCMHD) through Project EXPORT (Excellence in Partnership through Community Outreach and Research on Disparities in Health and Training). It enables academic scholars to collaborate with public, private and community organizations to focus on minority health disparity and work towards eliminating these disparities. ,
Health disparity is one of the challenges in India. According to India's National Commission on Macroeconomics and Health identified that health disparity is not solving because the lack of communication between researchers and policymakers as a major obstacle. The diversity and size of India make community sampling expensive and difficult. The country of one billion people spans 14 national languages, 6,000 dialects, and ''every possible religious denomination.'' ''It's not just (having access to) drugs and doctors,'' she said. ''It's a whole lot of issues - social determinants and political, cultural, educational, and economic forces - that really drive health." The U.S. is not alone in its focus on biomedicine. The Indian government is attempting to provide a better balance between public health and medicine in its country by establishing two public health schools. She explained that decades ago public health had many successes in India, particularly in the control of diseases such as smallpox and malaria. Then, in the 1960s and 70s, medical care took the fore, with public health taking a backseat. The new schools should help return public health to a more prominent place in the country. 
Oral health inequalities can be minimized through National oral health policy, which has to be implemented as a priority, with an emphasis on strengthening dental care services under public health facilities, health promotion approach through multi-sectoral involvement and principles of Ottawa Charter framework. 
This framework will now be used to review the available options to reduce oral health inequalities as follows: ,
1. Creating supportive environments: Recognizing the impact of the environment on the health and identifying opportunities to make changes conducive to health.
Fluoridating the mouth
Water fluoridation. Fluoridation of public water supplies is a proven public health measure that has been demonstrated to reduce caries experience, especially amongst socially deprived communities. Removing VAT on fluoride toothpastes. Fluoride toothpaste is the single most important reason for the dramatic decline in caries in the past 20 years.
Health promoting schools
The WHO Health Promoting Schools initiative aims at achieving healthy lifestyles for the total school population. Oral health promotion would be nutrition, smoking and accident prevention policies. In addition, efforts such as the Schools Meals and Nutrition Action are initiatives which aim to provide students with a range of food choices within schools including nutritional options. The Departments of Education and Health should expand the Health Promoting Schools programme to include all schools in socially deprived locations. Dental professionals should ensure that any opportunities to promote oral health are adopted within these programmes.
2. Building healthy public policy: Focusing attention on the impact on health of public policies from all sectors, and not just the health sector.
National and local food policies
The Minister of Public Health should create an Inter-Departmental forum to integrate Government policy to improve diet and nutrition. The Food Standards Agency should play a key role in this process. A reduction in the frequency and total consumption of non milk extrinsic sugars (NMES) will only be achieved through a national food policy, supported by regional and local initiatives.
Stricter controls on the advertising and marketing activities of the cigarette industry would be an essential element. The dental profession has an ethical and professional obligation to become actively involved in smoking cessation interventions.
Regulations on the importation, labelling and sale of paan and associated products should be enacted and enforced alongside the regulations on sale and promotion of tobacco. Effective prevention is dependent upon developing culturally sensitive interventions that address the social and structural basis of tobacco use amongst high risk populations. Sale of tobacco containing Paan (betel nut) is largely unregulated and many teenagers use these products.
3. Developing personal skills: Moving beyond the transmission of information, to promote understanding, and to support the development of personal, social and political skills which enable individuals to take action to promote health. Health education supports personal and professional development through providing information, education for health, and helping people to develop the skills needed to make healthy choices. Integrated oral health education input into the national curriculum is essential to foster the development of the necessary knowledge, attitudes and skills to promote oral health. In particular skills training such as decision making, assertiveness training and cooking should be included in personal and social development courses.
4. Reorienting health services: Refocusing attention away from the responsibility to provide curative and clinical services toward the goal of health gain.
The role of service commissioners
Population preventive programs such as fissure sealant programs targeted at schools.
Prescription of sugar free medications
Caries can be prevented by using sugar free medicines among vulnerable chronically sick children.
Free Dental services for special group of population
Like aged population, handicapped population, etc.
5. Strengthening community action: Community development strategies should aim to improve the capacity of less powerful groups by developing collective social networks and thus accessing resources. Such an approach has been rarely applied directly to oral health issues. Example, an oral health promotion programme in Newcastle and North Tyneside is using community link workers to facilitate improvements in oral health amongst socially deprived groups.
| Conclusion|| |
There is a need of deeper understanding of how fundamental causes of disparity shape community environments and how these environments, in turn, shape health. To improve health status and equity, we need to give proportionately greater attention to a prevention-oriented approach. Policies and organizational practices that improve the environments in which people live, work, learn, and play are powerful tools in reducing disparities. Every community is different, and understanding the factors that most influence health inequities is vital in designing strategic responses. We should be committed to translating available research into effective tools, practice, and policies.  Persistent and significant disparities in health among different population have prompted innovative forms of health practice, new ideas for health policy, and research. The most stark oral health inequalities are found in dental caries among preschool children. Reduction will only be achieved through the implementation of effective and appropriate health promotion policies which focus action on the underlying social, economic and environment causes of dental diseases.  We can reduce the effect of SES on health through ethnic-specific interventions which include social support, improve our cultural competence, target low social capital communities and resources to problems.
"We, or just one of us, can make a difference."
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