Social determinants of health and oral health: An Indian perspective

Abstract

Several conventional approaches have been tried in the past to resolve health inequities in India. However, achieving Universal Health Coverage (UHC) is yet to be fully realized as the benefits have been meager. The recent concept of targeting social determinants of general and oral health in order to achieve health for all has shown positive results in the developed as well as the developing nations. Based on the framework recommended by the Commission on Social Determinants of Health, several policies have been introduced and suitably backed up with the intention of providing health care even to people living in remote sections of the society. This paper intends to highlight the rationale for social determinants approach in Indian context, its application and future recommendations for the same. It is considered as a radical approach, and adequate measures have been implemented by health systems to achieve the desired targets without delay. However, in order to achieve UHC, redistribution of the available resources and converting the “normative” needs into “felt” needs of the people is going to be an uphill task to accomplish.

INTRODUCTION

Health is a complex entity that is directly and indirectly influenced by several factors, and an understanding of these factors is essential for the health services’ planners to plan and deliver effective treatment. Majority of the global burden of disease and the major causes of health inequities, found within and between different countries ascend from circumstances in which people are born, grow, live, work, and age. On the contrary, factors more commonly held responsible, such as access and use of health care services often have less impact on the community health.[1] Sustainable improvements in the health of the population and a reduction in health inequalities can be achieved by addressing factors which lie at the core of disease causation.[2] These factors are termed as “social determinants of health,” a term that incorporates the various determinants of health such as social, economic, political, cultural and environmental.[1]

The underlying influence of economic, environmental, psychosocial and political determinants has been reflected in the universal social gradient in general as well as oral health.[3] Despite rapid globalization ensuing globally, profound inequities in health, living and working conditions are experienced by millions.[4] Health system reforms in Cuba, Brazil and Thailand, have shown paramount success as they addressed the wider determinants of health inequities as a national priority and implemented reforms through both policy changes and grassroots-based actions.[5,6,7]

METHOD OF DATA COLLECTION

Literature search was conducted in PubMed and Google Scholar using the keywords: Social determinants of health, oral health, risk factors, health inequity, Indian context. Keywords were used either alone or in combination and search was restricted to the articles published in English language after the year 2000. The search retrieved 1289 published articles. References of these articles were checked for relevant secondary references, and the related articles feature of PubMed was also utilized. In order to obtain data pertinent to India, websites like Ministry of Health and Family Welfare, World Health Organization (WHO) and relevant data on Google Scholar were examined, without any restrictions on year of publication. Articles that discussed the important concepts of social determinants of health and oral health along with databases and articles relevant to Indian context were selected for the present review. Forty relevant articles were obtained and critically reviewed and appraised for this narrative review. Data on social determinants of health and oral health was obtained through the research work done by various authors from different countries and data relevant to Indian context was primarily obtained from the government websites and registries.

Conventional “downstream” approach versus “upstream” approach

Michael Marmot has famously quoted, “treating existing disease is urgent and will always receive high priority but should not be to the exclusion of taking action on the underlying social determinants of health.” Hence, from this behavioral “downstream” approach regarded as “victim-blaming” in nature, a conceptual shift is needed to the “upstream” approach that deals with the underlying social determinants of health.[3]

Isolation from other elements of health services has become one of the major drawbacks of modern dentistry.[8] The dominant and overly sustained “preventive” approach of dentistry tends to focus only on changing the behaviors of high-risk individuals and has been considered as unsuccessful in reducing the gaps in oral health inequalities. On the contrary, it may have amplified the oral health equity gap.[3]

Basis for the paper

Literature pertaining to social inequalities in health and oral health which represent the impact of the social environment on health and oral health, respectively, is scarce. Social environment is not immature and imprecise, but it is distinguished, and its distinct effects on health are discernible.[9] Controlling these factors has led to positive outcomes in developed countries and hence, they are gaining wide importance and acceptance in developing countries to improve health and lifestyles of the population.[10] Concept of social determinants is not new, albeit it keeps on changing with time. The circumstances in which people live are shaped by a wider set of forces inclusive of economics, social policies and politics.[11] Hence, this paper aims to describe the current scenario, recommendations and future implications for social determinants of health and oral health with data obtained from various researchers.

Rationale for social determinants in the Indian context

Social determinants need to be addressed as there is realization that there are huge diversities within and between classes, castes, gender and extensive regional variations in both, disease burden and response by the health care systems and others concerned with development. Disparities in exposure and vulnerability to diseases and health services accessibility are pronounced in India with the most affected people being the poorest and most disadvantage.[4]

It is a well-established fact that the health care system is the most critical social determinant of health.[12,13] Universal Health Coverage (UHC) in India necessitates the reform of the health systems. However, UHC will be possible only if there is simultaneous focus on social determinants and promotion of social equity. Steps toward promotion of social determinants such as food and nutrition security, social security, water, sanitation and work and income security are imperative, as are social inclusion and equity across gender, case and religious categories.[4]

Indians account for more than a fourth of the world's hungry. In line with the WHO's standards for children aged 3 years, 40% are underweight, 45% are stunted and 23% have wasting.[12] Several determinants lead to malnutrition that has an extended and mitigating lifetime influence on the health and wellbeing of women and their children.[12] High levels of food insecurity are prevalent even in economically developed states such as Gujarat, Maharashtra, Andhra Pradesh, and Karnataka.[14] In addition to the obvious findings in malnourished children of an increase in dental caries prevalence,[15] gingivitis in primary school children[16] and periodontitis in teenagers,[17] malnutrition has been associated with delayed tooth exfoliation and erroneous eruption patterns.[18] Malnutrition has also been shown to demote the salivary flow and significant changes in child mortality have been noted following an improvement in nutritional status of children.[19,20] Current nutrition programs in India emphasize on supplementary nutrition and preschool education for 4–6 years old. This is contradictory to the need to focus appropriately on the first 2 years of a child's life which is critical to prevent under-nutrition and its impact on general and oral health.[21]

Inadequate and poor quality of water or sanitation has been associated with poor health. A study conducted among urban poor communities of Mumbai over a year indicated that water related illnesses were accountable for almost one-third and two-thirds of all morbidity among adults and children, respectively.[22]

It is well-known that the socioeconomic position of individuals, groups and places are crucial attributes for the level of systematic health and disease.[23] Inequalities in oral health mirror those in general health.[3] Socioeconomic status affects the occurrence and severity of ill health not only among individuals and groups that are deprived or poor, but at every level of social hierarchy creating the social gradient in health.[23] For long-term ailments, rural Indian women are three times more likely to go without treatment than rural Indian men, a tendency noticed even among the nonpoor. Similarly, the treatment expenses are significantly smaller for women than men.[24] Besides gender, social status has also been linked with systemic neglect and poor health. It is striking that social and caste stratification determines the health, education, employment, social, and economic outcomes in India.[25] Although studies exhibit variable results, speculation is rife that socioeconomic status is associated with oral cancer. Assumptions laid down in favor of this association are access to health care facilities, health related behaviors, living environment and/or psychosocial factors.[23]

Dental Council of India's national survey[26] and several other studies[27,28,29,30,31] have shown that the prevalence of dental caries in children is between 40% and 80% while the periodontal conditions usually increase with age and are frequently found in rural areas. It is remarkable that the stated caries prevalence in school going children is irrespective of whether they live in urban, rural or semi-urban setup. Conversely, an important finding is an increase in prevalence of early childhood caries in the same age group in the rural counterparts.[32,33] Although caries prevalence might be similar in rural and urban areas of India, there is a vast difference in the proportion of people who receive the required treatment. Greater utilization of oral health care services noted in urban areas has been attributed to obvious reasons like greater awareness about maintenance of oral hygiene and better accessibility to health care centers.[34] Immense variation in the availability of dental professionals in different sections of the society can be accredited to the overcrowding of majority of Dental Colleges in the urban sectors and very few in the rural sectors.

Socioeconomic characteristics of the individual will be more crucial in determining visits for preventive services than visits for an actual treatment. The discretionary characteristic of dental care among low socioeconomic status people reflects the prioritization of needs rather than an unwillingness to seek dental care. Indians do not regard to dental care as a priority since they perceive the consequences of delaying it are not as severe and expensive as medical treatments.[23]

Acting on the social determinants of health

Traditionally, India has always backed a social determinants perspective in order to ensure UHC. Social determinants of health have been recognized and highlighted by the Bhore[35] and Sokhey reports,[36] the 2010 Annual Report to the People on Health[37] and the Draft National Health Bill.[38]

Comparatively, the 2010 Annual Report was more specific as it highlighted nutrition, access to safe drinking water, education, poverty and marginalization to be the key social determinants of health in India. The Draft National Health Bill indicated that health interests would guide the creation of minimum standards for food/nutrition, water, sanitation and housing, adding that an individual's right to the highest attainable standard of health could not be impaired on grounds of social or economic status.[37]

As indicated by the Commission on Social Determinants of Health,[39,40] action on multiple intersecting and overlapping social determinants is needed in order to achieve UHC. Currently, there are several government initiatives that have the potential to positively impact the well-being of all citizens, especially the poorest. Right to food under the proposed National Food Security Bill and the right to education for all children has been the primary focus. Reforms in the Public Distribution System and Integrated Child Development Scheme and procurement of nutritious food grains have been recommended to achieve the goal of health for all. Important steps taken to help and support the rural sections of the society also include recognition of land and forests as crucial assets and extension of the Rashtriya Swasthya Bima Yojana.[4]

Recommendations for Social Determinants of Health

Even though actions have been instigated on social determinants approach in order to achieve health equity, the results are not to be expected any sooner as it is a plodding approach. The High-Level Expert Group has endorsed this on-going action on social determinants and also recommends the following:[4]

• Initiatives, both public and private, on the social determinants of health and toward greater health equity should be supported

• A dedicated Social Determinants Committee should be set up at the district, state and national level

• Include Social Determinants of Health in the mandate of the National Health Promotion and Protection Trust

• Develop and implement a Comprehensive National Health Equity Surveillance Framework, as recommended by the Commission on Social Determinants of Health.

DISCUSSION AND CONCLUSIONS

Understanding of the “felt needs” of the masses and inculcating a positive attitude toward oral health is the first step to success in any approach. Formulating policies that cover the oral health expenses of the “poor” along with the general health expenses may prove to be a good initiative. It must be noted that hardly any actions taken or recommended have explicitly focused on oral health as a separate entity.

The dentist-to-population ratio of India stands at 1:10,000 in urban areas as compared to 1:2.5 lakhs in rural India.[34] This astonishing demographic dividend is attributable to the haphazard distribution of the majority of dental colleges in India in the urban sectors and a handful in the rural sectors. If we can achieve equitable distribution of dental professionals throughout the country by a reasonable way that creates a win-win situation for the professionals, as well as the masses, then most of the problems of accessibility to health care will be sorted out.[34]

India is a country typified by express industrial development and fiscal development along with demographic and disease alterations. Hence, it is imperative to tackle issues and challenges in order to achieve health equity. In addition to the established key determinants, additional issues will surface, such as the multifarious interactions between health and climate change. Eventually, the aim is to encourage actions to reduce health inequalities within as well as across nations. With adequate steps toward action on social determinants leading to UHC, India can play its role and participate in the greater cause of social justice and equity.[4]

Several challenges need to be addressed in order to achieve notable progress in reorienting dental public health practice and policy toward a social determinants approach. Closer co-operation and amalgamation of public health activities needs to occur at this critical phase of development in public health. Since the majority of the dental public health practitioners, policy makers and researchers have been trained in a bio-medical and behavioral archetype, they are unable to appreciate the viewpoint behind the social determinants agenda.[3] Now, the key priority should be to build and strengthen dental public health workforce in a way that there are sufficient numbers of personnel trained in a social determinants and population strategy framework. The fact that these challenges have shared aims underlines the importance of a well-co-ordinated approach.[3]

As of today, there are severe breaches in our knowledge of the social determinants of health and oral health. Further research is warranted to better understand the nature of health inequalities and the influence of biological, psychosocial, behavioral, environmental and political determinants on the same. Meticulous interventional studies are called for in order to evaluate and identify effective measures to bridge the gap between health inequality and the ultimate goal of social equity.[3]