Health and Social Care Inequalities | My Assignment Tutor

M.Sc. Public Health Health and Social Care Inequalities (PUB013-6) Unit Coordinator: Dr Nasreen Ali Summative Assessment: The role of socio-economic inequalities in the experience of oral health in the UK Name: Student ID: 1.0 Introduction In UK, although the health of the population is improving but over the past decade there has been a widening of the gap in health inequalities between different social-classes (House of Commons Health Committee, 2009). As according to a recent white paper ‘The Marmot Review’, health inequalities are a consequence of inequalities in society, which are influenced by circumstances in which people are born, raise, live, work and age (Marmot, 2010; Her Majesty’s-HM Government, 2010; Equality and Human Rights Commission, 2015). The foundation of these inequalities is laid down by their childhood experiences during the early years of life, giving rise to unfair differences and discrepancies in health throughout life (Marmot, 2010). They share the strongest association with socio-economic inequalities, as uneven dissemination of wealth and income ultimately leading to poverty and marginalisation of different individuals and populations (National Health Services-NHS Scotland, 2015a; Public Health England-PHE, 2015a; NHS, 2015b; Pitts et al., 2011; Watt, Williams and Sheiham, 2014). Despite the improvement in oral health over the past 30-years in UK, these inequalities are particularly existent and well-documented in oral health (House of Commons Health Committee, 2008). The oral health refers to the health of a person’s teeth, gums, supporting structures and soft tissues in the mouth and is defined as “absence of oral disease activity or progression with perceived well-being and without functional impairment” (Department of Health-DoH, 2005; Birch et al., 2015). It is regarded as one of the most common chronic diseases globally, with 90% of the affected population experiencing dental caries as the cause of poor oral health (Moyses, 2012). According to the white paper by the Dental Health Foundation-DHF Ireland (2011), dental problems can cause pain, chewing and speaking difficulties which ultimately have a profound effect on general health, quality of life as social interactions of the affected person (Moyses, 2012). Despite this, oral health disparities exists across the UK on a wide social gradient and there is a reported 50% higher probability of decayed teeth experience in poorer regions of UK, compared with the more affluent ones (Marshman, Nower and Wright, 2013; House of Commons Health Committee, 2008; DoH, 2005). Though, the gradient of oral health inequalities is widely evident across different measures of income, and shares the strongest bond with socio-economic inequalities (Shaw, Macpherson, and Conway, 2009), however, it is multi-faceted as age, ethnicity and access to health-care are also of important consideration (British Dental Association–BDA, 2014; Shen, Wildman and Steele, 2013; Watt, Williams and Sheiham, 2014). Therefore, this essay takes these factors into consideration and describes oral health inequalities in UK, followed by explanation of those inequalities. These factors are although inter-related (Fisher-Owens et al., 2007), but will be discussed separately, with all factors at some point influenced by socio-economic position-SEP. The focus is on the general population, with the disclaimer that oral health in prisoners, disabled people and other deprived communities have additional adverse oral health determinants (BDA, 2014). Finally, the last section outlines some current policies and strategies to address those oral health inequalities. 2.0 Describing oral health inequalities Health inequalities are differences in health experiences among different populations influenced by distribution of health determinants (World Health Organisation–WHO, 2016a), which will be described below in the context of oral health. 2.1 What is socio-economic status-SES? In this essay SES, SEP and social-class, despite of having different theoretical basis (Regidor, 2006), will be used inter-changeably. They refer to different exposures and experiences by individuals due to their social and economic position in the society (Galobardes et al., 2006; Baker 2014). The common indicators for measuring this position involves a person’s education, income, occupation and housing, which are essential in determination of social-class because of the influence they have on a person’s living standards defining their life-course (Regidor, 2006; Baker, 2014). As an individual’s health is defined by these features therefore, it is crucial that the relationship between SES and health is rationally construed (Graham, 2004). The health gaps between high and low SES, follows a social gradient where people on the lowest position of socio-economic spectrum have the poorest health and vice-versa (WHO, 2016b; Guarnizo-Herreno et al., 2013; Thomson et al., 2004; Tsakos et al., 2011; Sabbah et al., 2007; Steele et al., 2015). It gives rise to health inequalities as people on the upper-most part of the scale experience better health than the ones below them and this pattern continues till the lowest-level, showing an inverse relation between SEP and health risk-factors (Watt, Williams and Sheiham, 2014; Moyses, 2012; Dowler and Spencer, 2007). Likewise, oral health follows this same hierarchical socio-economic step-wise order, getting worse with each descending point (PHE, 2014a; Watt et al., 2015; Watt, Williams and Sheiham, 2014). 2.1.1 Relationship of SES and oral health inequalities among children In UK, though the general oral health has been improving over the past 40-years resulting in increasing number of caries-free children, health inequalities are still particularly evident (Chestnutt, 2013; NHS England, 2013). Currently, tooth-decay is closely associated with socio-economic deprivation and is more concentrated among the poor population who are considered at high-risk (Chestnutt, 2013; Pitts et al., 2011; NHS Scotland, 2005). There are considerable oral health inequalities across the UK, with 41% dental-decay in children from deprived communities in contrast to 29% from the more affluent ones (BDA, 2013). Additionally, there are differences in dental health experiences at national-level as dental-decay occurs in over 72% children in Northern-Ireland, compared to 44% in England, 60% in Scotland and 63% in Wales (BDA, 2013; Steele et al., 2015; NHS Scotland, 2005). More importantly, there are significant oral health inequalities even at the regional-level, as 64% more five-year-olds experience tooth-decay in North-West, compared to South-East England (Royal College of Surgeons-Faculty of Dental Surgery-RCS-FDS, 2015; PHE, 2013). Additionally, the variation continues among the upper-tier local authority level, fluctuating from 12.2% of dental-decay in Brighton and Hove to as high as 53.2% in Leicester, with a similar situation in lower-tier local authorities (PHE, 2013), which is possibly influenced by water fluoridation schemes and access to health-care in those regions (RCS-FDS, 2015). Besides, oral health is also influenced by the area characteristics as children from rural residence had the best overall oral health, possibly related to varying profiles of children in those areas (White, Steele and Fuller, 2015). Furthermore, children from income-deprived households were eligible for free meals at school (statutory benefit to children from families receiving income support), showed having poorer oral health compared to other children of same age (Pitts, Chadwick, and Anderson, 2015; Moyses, 2012; Watt et al., 2015). Apart from prevalence, caries severity was also significantly high among these children from lower social-class (Watt et al., 2015; Steele et al., 2015; Tsakos et al., 2015) (Figure-1). Furthermore, higher deprivation-level was directly proportional to children starting brushing later and less frequently, and having increased sugar consumption, which affected their oral health and made them twice as likely to experience oral problems (Watt et al., 2015; Tsakos et al., 2015; Steele et al., 2015). Consequently, making them responsible for one-fifth of hospital admission for teeth extraction in England (Watt et al, 2015). Moreover, low dental attendance and low accessibility of NHS dentistry was common in children who were eligible for free meals, as majority reported never going to the dentist compared to those not qualified for free meals (Watt et al., 2015; Tsakos et al., 2015). Consequently, the deprived children had greater unmet treatment needs, despite the fact that the necessity for treatment was greater amongst them (Tsakos et al., 2015; Steele et al., 2015), and they probably fail to avail the chance of prevention and early diagnosis of oral diseases. 2.1.2 Relationship of SES and oral health inequalities among adults Oral health status among adults also varies at national-level in the UK with 47% experiencing tooth-decay in Wales, compared to 30% and 28% in England and Northern Ireland, respectively (White et al., 2011). Also, there are variations among regions with 39% adults with obvious decay in West-Midlands dropping to 21% in South-East coast (White et al., 2011). The SES among adults as indicated by their occupations, shows oral health inequalities as routine and manual occupation households (lower social-class) had higher average decayed teeth with almost 50% more root-caries and 10% poorer oral health than the higher managerial and professional occupational households (Pomerleau and McKee, 2005; White et al., 2011). Also, managerial and professional occupation households were more likely to have natural teeth with healthy tissues, which is a good indicator of a person’s oral and general health, than adults from the lowest socio-economic occupational households (Fuller et al., 2011). These differences could be attributed to oral health behaviour in adults from lower occupational background, who have less dental hygiene practices and dental attendance and increased smoking prevalence compared to higher occupational households (Chadwick et al., 2011). Therefore, these all factors combine results in a clear gradient between the SEP and negative oral Impacts on daily performance, severely affecting the quality of life of the lower socio-economic population (Nuttall et al., 2011a). 2.2 Oral health inequalities related to older age Oral health inequalities are not only prevalent among different socio-economic groups with the disadvantaged having the poorest health, but they also varies with age, with obvious tooth-decay being the highest among those aged 75-84 years (White et al., 2011; Shen, Wildman and Steele, 2013). This is especially evident for dental root-caries as the proportion of root-exposure increases over 90% in 55-years and older, also tooth-wear and gingival bleeding increases, whereas the number of teeth retained decreases over 85-years of age when almost 50% are edentate, compare to 0.5% among 25-34 year-olds (White et al., 2011; Fuller et al., 2011). Furthermore, oral hygiene habits also decreases with increasing age causing significant poor oral health and contributes in deterioration of quality of life in older age (Pitts et al., 2011; Chadwick et al., 2011). However, the factor of age is also influenced by their SES, as older population from lower social-class reports poorer oral health than the rest (NHS, 2014; Ramsay et al., 2015; Shen, Wildman and Steele, 2013) (Figure-2). 2.3 Oral health inequalities amongst minority ethnic groups Ethnicity is a multi-faceted fluid term that defines a group of people with certain common characteristic, including geographical area, familial origins, cultural traditions and languages (Bhopal, 2004). There are different ethnic minority groups in the UK who experience considerable oral health disparities (Antunes et al, 2003; Nanayakkara et al, 2013; Delgado-Angulo, Bernabe and Marcenes, 2015). As studies an expressively greater number of dental-decay amongst Black and minority ethnic-BME groups compared to White British, essentially influenced by SES (Bedi, Lewsey and Gilthorpe, 2000; Marcenes et al, 2013; Marshman, Nower and Wright, 2013). Also, children from South-Asian ethnic minorities are less likely visit dentists and even who do visit, usually do because of oral problems instead of a routine dental check-up (NHS England, 2013). Additionally, these groups have a higher risk of developing oral cancer compared to their white counterparts (Csikar et al., 2012; Millward and Karlsen, 2011). Though, these associations between oral conditions and ethnicity are quite evident, however belonging to a particular ethnic minority does not imply poor health as these are often confounded by SEP (Watt and Sheiham, 1999; Marshman, Nower and Wright, 2013). 2.4 Oral health inequalities related to gender Gender inequalities are socially constructed and often cause discrimination against women which affects divisions of work, freedom, and education all of which ultimately impacts their health and limits their access to health-care (WHO, 2008; Darshana and Nandita, 2014). Also, pregnancy, hormonal-flux and dental anxiety in females are common poor oral health risk-factors (Nuttall et al., 2011b; BDA, 2014). However, more men experience poor oral health compared to women, which is possibly a result of the increase use of oral health cleaning methods in females (White et al., 2011; Chadwick et al., 2011). Also, oral cancer occurrence is 2-3 times higher in males, because of their higher smoking rates (Millward and Karlsen, 2011; NHS England, 2013). Though, smoking is significantly associated with health inequalities as it is more prevalent among disadvantaged communities (Blas and Kurup, 2010; Richardson, 2001; McEwen, 2013). However, gender-related oral health inequalities are more health behaviour oriented than associated with socio-economic differences (Steele et al., 2015; Watt et al., 2015). 3.0 Explaining inequalities in oral health The mentioned oral health inequalities, are under-pinned by a number of reasons, which are explained below. 3.1 What are social determinants of health? The social determinants of health are the conditions in which a person is born, grows up, lives, works and ages, shaped by economics, social and political forces (Marmot, 2010; WHO, 2016; WHO, 2008). As oral health potentially affects the health of the whole body, therefore, its determinants have a multi-level perspective including factors which effects general health (Gil-Montoya, 2015; Benjamin, 2010; Kandelman, Petersen and Ueda, 2008). The Dahlgren and Whitehead’s model (1991), outlined a multi-dimensional approach to explain these determinants by different influential factors. This similar approach was however adopted by Fisher-Owens et al. (2007), to explain the complex concepts and their interaction at the multi-level to influence oral health. Consequently, dental health can be traced to a person’s use of dental care, health practices and demographic attributes, influenced by their SES, culture, family health status and support which is further under the influence of the community’s environment and health-system (Fisher-Owens et al., 2007). Therefore for a child’s oral health, family and community-level factors play an important role, all of which are inter-related (Fisher-Owens et al., 2007). The post-code lottery also contributes to these variations as across different areas in UK there are significant dental cost and water fluoridation differences (Evans, 2015; BDA, 2012). These determinants are fluid, as they observe the theory of inter-sectionality in forming an inter-locking system to influence health inequalities (Smith, Hill and Bambra, 2016). However, few of these inter-related oral health determinants (Figure-3) will be analysed separately below. 3.2 Impact of socio-economic class Oral health is unevenly distributed across UK, with higher prevalence of dental diseases in highest deprived areas compared to lower deprived areas (Health and social care information centre–HSCIC, 2013; Shen, Wildman and Steele, 2013; Watt et al., 2015). This results from different socio-economic factors, including level of education, income, occupation, community-index and social-class (Costa et al, 2012; Guarnizo-Herreño et al., 2014). Income mainly affects in accessing and affording dental services, health necessities and healthy lifestyle options, whereas education effects oral health awareness and perceptions which influence on oral health-related behaviours (Tsakos et al., 2015; Blas and Kurup, 2010). The occupational-class however, reflects their economic structure, support network and also stress-level, as differential exposures can make people prone to risky occupations in unsafe surroundings (Guarnizo-Herreno et al., 2014; Tsakos et al., 2015; Blas and Kurup, 2010). Consequently, stress leads to unhealthy lifestyle including poor diet, alcohol consumption and smoking, all which adversely effects oral health (Blas and Kurup, 2010). All these factors, subsequently affects the people’s attitude, behaviours and affordability towards their child’s oral health (White et al., 2006). Consequently, affecting the health beliefs and behaviours of the child, affecting how they take care of their own teeth at home (Watt et al., 2015; White et al., 2006). It ultimately forms a social-gradient resulting in higher dental-decay rates in children eligible for free school meals and adults in manual occupations, representing poor oral health in lower-social class (White et al., 2011; 2010; Al-Kaabi et al., 2015; Tsakos et al., 2015). As a result they have less frequent dental check-ups, more extensive dental-decay and consequently, negative views about their own oral health which greatly impacts their daily lives (Tsakos et al., 2015). 3.3 Impact of old age Age has a similar gradient as social-class, with young on top and oldest at the bottom and oral health descending down the scale forming evident oral health inequalities (Watt, Williams and Sheiham, 2014). They have high caries rate due to increased susceptibility caused by greater dental root-exposure, causing tooth loss which requires them to wear denture which further compromises oral hygiene by making brushing difficult and trapping food (PHE, 2015b). Also, long-term conditions like arthritis, Parkinson’s disease and dementia can compromise ability to brush teeth, and can make them completely dependent on their carers for dental hygiene and appointments potentially leading to poorer oral health (PHE, 2015b; Karki, Monaghan and Morgan, 2015). Furthermore, taking medicines for these conditions causes dry-mouth, which leads to intake of more sugary drinks to keep the mouth hydrated causing caries (PHE, 2015b). However, in the life-course approach, early years affected by poor socio-economic conditions are the most important health determinants as they have life-long effects (DoH, 2009). Therefore, these conditions including income, housing, employment and access to health significantly intersects with old age in affecting oral health (Ramsay et al., 2015). Consequently, when oral health inequalities are measured by the number of teeth remaining, edentate person signifies worst oral health with the lowest income (Shen, Wildman and Steele, 2013). As this measurement underlines how inequalities function over life-long periods, resulting from cumulative damages by dental diseases, individual’s behaviours and other related determinants (Shen, Wildman and Steele, 2013). Older age also establishes health inequalities related to accessing health services, a problem which can probably worsen in future with increasing number of older people in the UK (Brocklehurst and Macey, 2015). 3.4 Impact of ethnicity Like mentioned before, BME in UK have poorer oral health than White British, which is potentially because of their different oral health understanding, substantially influenced by their related cultural and religious influences and perceptions (Marshman, Nower and Wright, 2013; Corrigan, 2001; NHS England, 2013). Culture also influences diet, as few ceremonies contain sugar-laden foods as an essential part (Scambler et al., 2010), also, in some cultures babies are bottle-fed for longer with added sugar in their drinks (Watt, 2000), all of which causes caries. Additionally, religious beliefs, not trusting Western medicine and familial roles plays part in health decisions of ethnic minorities (Darshana and Nandita, 2014). As, in Muslim religion the use of miswaak can cause slight dental abrasion and wearing hijab can potentially hinder in oral access and requires careful consent (Darwish, 2005). Moreover, ethnic minorities also experience linguistic barriers, as evidence suggest that interpreters are needed in dental clinics but are not used, which leads to dental treatment being postponed as the patient fails to understand the treatment procedure (Thalassis, 2009; Marshman, Nower and Wright, 2013). This language barrier also impacts on the provision of dental services, as it is crucial for acquiring consent, reaching a diagnosis and understanding the treatment and its severity by the patient to avoid under-estimation or over-estimation of their condition (Thalassis, 2009). Also, this patient-provider miscommunication, can potentially lead to inappropriate medications use and loss of follow-up care (Darshana and Nandita, 2014; Mullen et al., 2007). Apart from linguistic barrier, ethnic minorities also experience other barriers to attending regular dental care including mistrust of dentists, cost, anxiety, cultural misunderstandings, hygiene concerns, lack of information and interest (Newton et al., 2001; Thalassis, 2009; Darshana and Nandita, 2014). Also, the lack of diversity in the health-care staff (Darshana and Nandita, 2014), potentially lacks cultural sensitivity and competence in the dental services can potentially be a barrier. Ethnic minorities also perceive a lack of respect, discrimination and poorer service provision from the dentist because of their background, leading to clinical errors, and rushed treatment provision according to them (Thalassis, 2009; Marshman, Nower and Wright, 2013; Darshana and Nandita, 2014). Nonetheless, some diseases are more common in certain ethnicity and there this discrimination do not play a significant role (Darshana and Nandita, 2014; Marshman, Nower and Wright, 2013). For instance, chewing tobacco which is a determinant of oral cancer is a cultural habit in South-Asian communities, which is related to some social ceremonies (NHS England, 2013; Millward and Karlsen, 2011; NHS-HSCIC, 2005). Also, smoking is socially acceptable and in fact helps in socialising among Bangladeshi men, which is one of the principal causes of oral inequalities (Millward and Karlsen, 2011). This association between oral health and these factors is complex and often confounded by SES (Marshman, Nower and Wright, 2013), as ethnic minorities identify cost and anxiety of dental services as barriers to dental access (Croucher and Sohanpal, 2006). Also, dental services are costly and require a lengthy form to be filled for payment exemption which can be problematic for people with linguistic and literacy difficulties (Marshman, Nower and Wright, 2013). 3.5 Impact on access and utilisation of health The oral health discrepancies resulting from limited access to health-care are influenced by the cost, sub-optimal relation with dentist, trust and confidence in dentist and attitude and responsiveness of the dentist (Nuttall et al., 2011b; Vanobbergen et al., 2007). Subsequently, poor communication with the dentist leading to uncertainties regarding dental treatments, costs and reimbursement facilities were all reported barriers, common in ethnic minorities and lower SES groups (Mullen et al., 2007; Thalassis, 2009; Vanobbergen et al., 2007). Also, different ethnic groups prefer female dentist or dentist from their own ethnic background (Mullen et al., 2007), whereas amongst Muslims ingestion of any fluid is not allowed during the month of Ramadan (Darwish, 2005), all of which are potential barriers in accessing dental services. Moreover, travelling time associated with poor house management and other priorities (Vanobbergen et al., 2007), as well as structural barrier of transport or different health conditions among older population (BDA, 2002; PHE, 2014b), acts as barriers to accessing to dental health. Furthermore, access to health-care is also limited due to cost as adults are supposed to pay for dental services unless exempted (Marshman, Nower and Wright, 2013). Also, lower occupational households report less dental attendance related to their negative interaction with their dentist and experience greater dental anxiety compared to higher social occupational class (Nuttall et al., 2011a). Therefore, coast and dental anxiety are the foremost barriers to regular dental attendance, especially in ethnic minorities and older population (Mullen et al., 2007; Borreani et al., 2008). This causes inequalities in oral health in relation to accessing health-care services, undermined by the socio-economic inequalities (Shaw, Macpherson, and Conway, 2009). 4.0 Health strategies–Current policies The Health and Social Care Act in 2012 in UK, conferred responsibilities on local authorities to address the underlying oral inequalities, by focusing on children and young people-CYP by giving them the best start in life (PHE, 2014a). It recommends a place-based approach to be implemented to support CYP through early years, schools and community settings to maintain good oral health and have unimpeded access to dental services, which will potentially reduce the social gradient’s steepness through a life-course approach (National Institute for Health and Care Excellence-NICE, 2014; DoH, 2009). Similarly, a Scottish national programme Child-smile was formed, to reduce inequalities in oral health and improve access to dental services among children (NHS Scotland, 2014; Macpherson et al., 2010) (Figure-4). It provides dental packs, varnish applications and offers supervised tooth-brushing to children, it also creates oral health awareness and promotes early dental registration of the child (NHS Scotland, 2014). There are also similar programmes in Wales and Northern-Ireland for promoting oral health among children (Chestnutt, 2013; BDA, 2014). Evidently, these programmes have been effective in reducing oral health inequalities, by providing an integrated oral health service (Macpherson et al., 2010; Chestnutt, 2013). Furthermore, water fluoridation policy is considered an effective way to reduce oral health inequalities (Chestnutt, 2013; NICE, 2014; BDA, 2014). Though, it lacks implementation in Scotland, Wales and Northern Ireland, however in England, almost six-million people benefit from it, resulting in less tooth-decay and related hospital admissions among children compared to non-fluoridated areas (Chestnutt, 2013; RCS-FDS, 2015). Therefore, the RCS-FDS (2015), recommends water fluoridation schemes to be implemented throughout UK for reducing oral inequalities. Moreover, BDA published oral health inequalities policy which emphasises on an integrated preventive approach to oral health by the social and health-care providers, by providing counselling against smoking and alcohol cessation schemes (BDA, 2009). It includes integration of dentistry into primary care, respect for cultural sensitivities along with a multi-agency approach where health, local authority and voluntary organisations work together in reducing oral health inequalities (BDA, 2014). However, despite these policies, oral health inequalities are still evident in creating an unacceptable health gap in UK (BDA, 2009). Therefore, PHE (2014a) recommended a new analytical approach to combat decay rates in the lower SES, by commissioning interventions according to local oral health needs of the community. Also, for sustainable improvement in oral health, NHS Scotland (2005) recommends, high quality and easily accessible dental services, whereas DoH (2005), recommends to empower people to take control of their oral health, for instance policy change in schools to promote healthier food and drink options (NICE, 2014; BDA, 2014; Chestnutt, 2013). As there are no existing quick fixes to improve oral health (DoH, 2005), therefore these recommendations need consideration for sustainable implementation to reduce oral health inequalities. Conclusion In conclusion, this essay has evaluated oral health inequalities and have highlighted a number of issues associated with them. Though, oral diseases and their consequences have a cumulative nature because of which it is not easy to measure its inequalities. However, the SEP is reported to be the foremost oral health determinant, which mainly affects through income, education and occupational factors (Fuller et al., 2011; NHS Scotland, 2005; Baker, 2014). Nonetheless, this social-class also intersects with other social determinants like old age, ethnic minorities and access to health-care at family and community-level in affecting oral health inequalities. (Fisher-Owens et al., 2007). Determinants of oral health inequalities are therefore multi-layered and multi-faceted and come together to intersect at different levels in an individual’s life to affect their oral health (Watt, 2014; NHS Scotland, 2005). As underlined by the recent white paper (Marmot, 2010), these inequalities take a life-course approach as health experiences during the early life years, gives rise to health discrepancies later in life. Therefore, a multi-dimensional life-course approach is the key to decrease the social gradient in oral health, by tackling the wider health determinants which are determined by completely preventable social, environmental and behavioural factors, throughout an individual’s life which eventually have an influential role in their future life-chances (Parish, 2011; Irwin, Siddiqi and Hertzman, 2007). 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