Addressing Inequalities in Oral Health Access and Outcomes
Understanding Oral Health Disparities
Over recent years, there have been major advances in improving oral health through prevention, diagnosis, and treatment of diseases. However, these improvements have not been uniform. Generally, the most disadvantaged individuals and communities experience worse health standards. These differences reflect variations in socioeconomic development between regions and countries. Notably, these inequalities occur with increasing intensity even in the most egalitarian and developed countries and communities.
The Concept of Health Inequality
The concept of inequality in relation to health refers to the differences in the distribution of health conditions among the population. Inequality is related to differences in opportunities and resources available to people of different social classes, determining that the most favored individuals present a better health status. These differences would be avoidable if everyone had equal access to health.
Insights from the Black Report
The Black Report (UK) revealed significant social inequalities in health and proposed four possible causes:
- Methodological errors in social analysis.
- Selection bias in the study.
- Health-related behaviors.
- Material causes.
In his report, Black emphasized the material explanation as the most important factor.
Oral Health and Inequality in Spain
Analysis of survey data in Spain reveals a significant decline in caries among children. However, this improvement is not uniform; certain groups of individuals and communities continue to accumulate high levels of disease, presumably associated with the most disadvantaged segments of society. The percentage of individuals who keep their natural teeth increases with income. Overall, decayed or extracted teeth due to caries are more numerous in adults with lower socioeconomic status. The presence of fillings acts as a sensitive indicator of socioeconomic status, being 2.5 times more frequent in the higher socioeconomic group compared to the lower one.
Although Spain has a universal and equal public health system, the vast majority of dental treatments (approximately 80%) are private. While general health inequalities exist, these are more pronounced when analyzing oral health in relation to socioeconomic status. Interestingly, these inequalities do not necessarily translate into the worst oral health indicators overall compared to other nations. Spanish population data show that the number of teeth present and healthy is at the upper end of all the countries studied. This evidence supports the thesis of various authors regarding the limited impact of dental services with a purely restorative philosophy on improving the oral health of populations.
Inequalities in Use of Oral Health Services
Health services are used differently by different social classes, despite having proved effective in relieving pain, curing disease, and improving quality of life. The use of health services is related to several factors:
- Predisposing variables: Defined as determinants of use, not direct causes. These include age, gender, socio-demographic factors (social class, education, work, race), and beliefs/values.
- Enabling variables: Refer to the conditions that ensure the ability and access to health services. These include family resources (transport, income, time availability) and system accessibility (service availability, physical access, payment ability, acceptability).
- Need: Relates to the need felt by the patient (subjective need) and the need determined by clinicians (objective need).
It is important to differentiate between:
- Acceptability: The patient’s perception of the benefits the resource has to offer.
- Accessibility: The supply and ease of reaching health services.
- Use: Refers to the actual utilization of services, influenced by both supply and demand factors.
Strategies Addressing Common Risk Factors
Common strategies to tackle these issues include:
- Reducing the unequal burden of oral diseases, especially among poor and/or marginalized groups.
- Promoting healthy lifestyles and reducing risk factors for oral health that stem from environmental, economic, and social causes.
- Developing oral health systems that improve equity in health procurement, meet legitimate demands, and are funded equitably.
- Creating oral health policies based on the integration of national and community health initiatives.