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Global Oral Health Inequalities: Task GroupImplementation and Delivery of Oral Health Strategies
A. Sheiham, D. Alexander, L. Cohen, V. Marinho, S. Moyss, P.E. Petersen, J. Spencer, R.G. Watt and R. Weyant ADR 2011 23: 259 DOI: 10.1177/0022034511402084 The online version of this article can be found at: http://adr.sagepub.com/content/23/2/259

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Global Oral Health Inequalities: Task Group Implementation and Delivery of Oral Health Strategies
A. Sheiham1*, D. Alexander2, L. Cohen3, V. Marinho4, S. Moyss5, P.E. Petersen6, J. Spencer7, R.G. Watt8, and R. Weyant9
Department of Epidemiology and Public Health, Dental Public Health Unit, UCL, 1-19 Torrington Place, London WC1E 6BT, UK; 2FDI World Dental Federation, Geneva, Switzerland; 3National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA; 4Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, UK; 5Pontifical Catholic University of Paran, Oral Health Postgraduate Program, Curitiba, PR, Brazil; 6World Health Organization, Global Oral Health Program, Department of Chronic Disease and Health Promotion, Geneva, Switzerland; 7Australian Research Centre for Population Oral Health, School of Dentistry, University of Adelaide, Australia; 8Department of Epidemiology and Public Health, UCL, London, UK; and 9Department of Dental Public Health, School of Dental Medicine, University of Pittsburgh, PA, USA; *corresponding author, A.Sheiham@ucl.ac.uk Adv Dent Res 23(2):259-267, 2011
1

dental fraternity needs addressing. To re-orient oral health research, practice, and policy toward a social determinants model, a closer collaboration between and integration of dental and general health research is needed. Here, we suggest a research agenda that should lead to reductions in global inequalities in oral health.

INTRODUCTiON

he establishment of the Global Oral Health Inequalities Task Force coincides with worldwide recognition that health inequalities are an important public health issue. The WHO Commission on Social Determinants of Health (CSDH, 2008) highlighted that there have not been sustainable strategies to reduce inequalities and prevent serious non-communicable diseases. This paper reviews the literature on social determinants of health inequalities and links that information to research and policies on implementation of dental strategies to reduce oral health inequalities. Recommendations are then made for research to guide policies on reducing oral health inequalities.

ABSTRACT
This paper reviews the shortcomings of present approaches to reduce oral diseases and inequalities, details the importance of social determinants, and links that to research needs and policies on implementation of strategies to reduce oral health inequalities. Inequalities in health are not narrowing. Attention is therefore being directed at determinants of major health conditions and the extent to which those common determinants vary within, between, and among groups, because if inequalities in health vary across groups, then so must underlying causes. Tackling inequalities in health requires strategies tailored to determinants and needs of each group along the social gradient. Approaches focusing mainly on downstream lifestyle and behavioral factors have limited success in reducing health inequalities. They fail to address social determinants, for changing peoples behaviors requires changing their environment. There is a dearth of oral health research on social determinants that cause health-compromising behaviors and on risk factors common to some chronic diseases. The gap between what is known and implemented by other health disciplines and the
DOI: 10.1177/0022034511402084 International & American Associations for Dental Research

DEFiNiTiONS OF HEALTh INEQUALiTiES AND SOCiAL DETERMiNANTS OF HEALTh INEQUALiTiES

Inequalities in health are universally recognized as a major problem (CSDH, 2008). They are inequalities in peoples capability to function and to make choices. There is substantial inequality in exposure to health risks. Inequalities are not simply the poorest experiencing less-than-optimum health. There is a gradient of risk across the whole population the lower a persons social position, the worse his/her risks and health the poor and disadvantaged people have higher risks of disease and suffer from worse health conditions (Sanders, 2007). Health inequalities refer to socio-economic inequalities in health. Those which relate to other structures of inequality are labeled as gender or ethnic inequalities in health (Graham, 2004a,b). Grahams

Key Words
Community dentistry, dental public health, prevention, risk, social determinants, health disparities.

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(2004a,b) typology of classifications of health inequality distinguishes between the poor health of socio-economically disadvantaged people, health gaps between different groups, and social gradients across whole populations. Health inequalities can be considered unjust and avoidable when populations are made vulnerable by underlying social, political, economic, and legal structures. Equity is an ethical principle consonant with human rights principles. Since inequalities in health are deemed unjust, a moral judgment, they are considered health inequities (Whitehead, 1990, 1992). The definition and measurement of health inequity require a normative decision about social justice and fairness (Daniels, 2006). Inequality in health and oral health shows little sign of narrowing, despite explicit commitments to tackling health inequalities enshrined in international charters (WHO, 2000, 2005a). Attention has therefore been directed at the determinants of the major health conditions and the extent to which those common determinants vary within, between, and among groups, because if the nature of inequalities in health varies markedly across groups, then so must the underlying causes. Tackling inequalities in health thus requires a range of strategies tailored to needs of each group and each determinant along the social gradient. The unequal distribution of determinants underlies health inequalities. The CSDH (2008) defines social determinants of health (SDH) as the structural determinants and conditions of daily life responsible for a major part of health inequities among and within countries. Health determinants include social and physical environment, individual behaviors, genetics, and the health care system. Social Determinants of Health Inequalities (SDHI) combines the two concepts to emphasize the role of social and economic conditions in peoples different rates of health and illness.

A CRiTiQUE OF ORAL HEALTh AppROAChES TO PREvENTiON

In some industrialized countries, the mouth is the most expensive part of the body to treat (Kohlmeier et al., 1993; Schneider et al., 1998; Bauer et al., 2009). The dominant dental restorative approach is not viable in most countries, particularly in lowincome countries where more than 90% of dental caries is untreated. There, the cost to restore one tooth per 6- to 18-yearold child would cost between $US1,618 and $US3,513 per 1,000 children. That exceeds the available resources for essential public health care for children of many low-income countries (Yee and Sheiham, 2002). A critique of the USA dental care system sums up the situation worldwide: A system focused primarily on treatment of disease in individuals is not economically sustainable, socially desirable, or ethically responsible. The understanding exists to prevent a very large proportion of oral diseases (Gooch et al., 2009; Truman et al., 2002), and community-based prevention generally is cost-saving compared with a treatment-focused approach, particularly for communities and individuals at high risk for disease (Tomar and Cohen, 2010). The principal shortcoming of oral health approaches to prevention and to reduce inequalities is failure of oral health

researchers and policymakers to collaborate with groups involved in research and policies on proximal determinants of health common to most diseases, namely, the Common Risk Factor Approach to preventing non-communicable disease (Grabauskas, 1987). The WHO Assembly concluded that Experience clearly shows that they are to a great extent preventable through interventions . . . (WHO, 2008). This gap between what is known and not implemented by policymakers is repeatedly emphasized by the WHO. Global health urgently needs to apply the body of evidence-based policies, strategies and approaches of health promotion developed over the past twenty years (Petersen, 2009). This failure to address why current knowledge and evidence is seldom put into practice must be placed as a high priority on the agendas and workplans for major international governmental and non-governmental organizations. Specifically in the oral health sector, the International Association for Dental Research, the International Federations of Dental Educators and Associations, and the World Dental Federation, together with their regional organizations and national structures, must develop plans and provide leadership. All these organizations must be cognizant of their responsibilities to civil society and take collective action to ensure knowledge transfer and action. The reports of the Task Groups on specific oral diseases indicate that, despite dramatic declines in dental caries and periodontal disease, there are persistent inequalities in oral health (Petersen, 2005a). The dramatic decline in dental caries demonstrates that marked improvements are achievable within a generation. Caries in 12-year-olds in industrialized nations declined from a DMFT of about 6 to 1 in 25 years. No other chronic disease has declined so rapidly. Despite the decline, few dental research priorities and approaches to treatment and prevention have changed. Indeed, more resources are now allocated to research on new risk factors and at-risk individuals (Rockhill et al., 2000) instead of focusing on sick populations (Rose et al., 2008). The gap between what is known and implemented by other health disciplines and the WHO and the dental fraternity needs addressing (Petersen and Kwan, 2010). A rigorous exploration of determinants of the decline in caries and periodontal disease would provide information to apply to reducing inequalities in oral health and point to the greater importance of health promotion, a subject with a low priority in dental research. There is a dearth of oral health research on social determinants and risk factors common to numerous chronic diseases and on the social and environmental conditions that cause health-compromising behaviors. This link between social conditions and health is not a footnote to the real concerns with health health care and unhealthy behaviors it should become the main focus (Marmot, 2010). The dramatic reductions in caries and periodontal disease resulted from changes in behaviors together with alterations in manufacturing practices and the addition of fluoride to toothpaste or made available via water and salt fluoridation. Dental services explained only 3% of the variation in changes in 12-year-old caries levels, whereas broad socio-economic factors explained 65% (Nadanovsky and Sheiham, 1995). The implication is that major improvements in

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behaviors. All Western countries . . . recognize that interventions which only tackle adverse health behaviors will have little success: they offer micro-environmental solutions to a macro-environmental problem (WHO, 2005b). The differences between micro- and macro-determinants of inequalities in health are highlighted by findings that individual behaviors account for about 25% of health inequalities (Frank, 1995). While good evidence-based health care is essential to reduce health inequalities, the effects of health care are undermined by social determinants which affect peoples health and opportunity for good health (Tugwell et al., 2007). This is particularly important in relation to inequalities of oral health, because effective dental treatments rely heavily on health-promoting behaviors and adherence to recommended regimens. There is growing recognition that a good understanding of the social determinants of health inequalities is essential for the development of effective public health policy. What is of primary concern is the distribution of health determinants (Judge et al., 2005). The persistence of large health inequalities . . . underscores the fact that these inequalities must be deeply rooted in the social stratification systems of modern societies (Mackenbach, 2005). One of the most important insights in modern public health was by Rose (Rose, 1985; Rose et al., 2008). Rose emphasized the importance of assessing the causes of the causes. Concern about determinants of health led to the WHO CSDH (2008). The CSDH analyzes causes of ill health and the causes of the causes and provides convincing evidence that structural determinants and conditions of daily life, the social determinants, are major determinants of health and inequalities in health. Changing the social determinants of health should lead to improvements in health equity. The major conclusions of the CSDH are a wake-up call for health professionals, policymakers, and politicians. They herald a large shift in thinking about policies on promoting oral health and reducing inequalities (Kwan and Petersen, 2010). The CSDH is an optimistic report, since it considers that if the actions recommended are adopted, the health gap can be closed in a generation. The complexity of causes of inequalities in health means that multi-sectoral action is required in public health to tackle the macro-environmental factors and the physical and social environment, as well as adverse health behaviors and access to health care.

prevention of diseases tend to follow social changes alterations in dietary patterns and breastfeeding, smoking, and oral cleanliness, and in the availability of products such as fluoridated toothpaste or water or salt fluoridation. The improvements in oral health demonstrate that the means for effectively controlling oral diseases are known (Truman et al., 2002). Yet a major problem facing policymakers is the persistent and universal challenge of how to tackle oral health inequalities effectively. The question that needs answering is, Why are there persisting inequalities in oral health? To answer that question, we should first look at the determinants of inequalities in health, because the major chronic diseases, and that includes caries, periodontal disease, and cancer, have risk factors in common (Sheiham and Watt, 2000). No other health discipline has such detailed scientific information as we have on the causes of oral diseases. Moreover, there are countless clinical trials on how to prevent the two major oral diseases. The fundamental gap in knowledge is how to translate findings into sustainable effective programs for groups and populations (Petersen and Kwan, 2010). The reason for the gap is the widespread fundamental conceptual gulf among oral health researchers and policymakers regarding clinical research and implementing findings in populations (Petersen, 2005b). Moreover, there is a tremendous gap in research for oral health among developed and developing countries. The limitations of most current approaches to improve oral health and reduce inequalities in oral health have been cogently summed up by Kwan and Petersen (2010). Measures that focus on downstream factors only, such as lifestyle and behavioral influences, may have limited success in reducing oral health inequities. . . . Such approaches . . . fail to address the wider social determinants that cause people to get ill in the first place. . . . It is necessary to address the root causes, tackling social determinants and the environment. Approaches that take into account the principles of the common risk factor approach, which promotes coordinated work across a range of disciplines, and the Ottawa Charter for Health Promotion, may be promising.

A SOCiAL DETERMiNANTS OF HEALTh AppROACh TO REDUCE INEQUALiTiES iN HEALTh

Social determinants of health (SDH) are the structural determinants and conditions of daily life responsible for a major part of health inequities between and within countries (CSDH, 2008). Determinants of health inequalities are different from determinants of health (Graham and Kelly 2004). Determinants of health inequalities are about the causes of the causes, what are the economic, social, and physical environmental causes of sugar consumption or smoking that is, the fundamental structures of social hierarchy and the socially determined conditions these create in which people grow, live, work, and age (Marmot, 2007) whereas determinants of health are more related to proximal causes, such as health-compromising behaviors. Macro-environmental factors (the national socio-economic factors and the physical and social environment) are the principal determinants of inequalities in health. Ultimately, all these factors influence health

ThE CAUSES OF HEALTh-RELATED BEhAviORS

Social inequalities in health have been associated with social differences in behaviors. Risk factors vary and operate differently for different socio-economic groups (Marmot et al., 1999). Health risk behaviors . . . are closely tied to both SEP and health outcomes (CSDH, 2007). In the Marmot review of health inequalities in England, attention was not only on causes of illhealth but also on the causes of the causes (Marmot, 2010). Smoking, obesity, and heavy drinking are causes of ill health, but what are the causes of these behaviors? The behavioral choices people make are rooted in their social and economic circumstances (Marmot, 2010). Rather than focusing on individualized strategies to change health behaviors, the more

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fundamental causes of ill health need to be addressed. Such principles are highly relevant to promotion of oral health, and appropriate strategies have been suggested recently by the WHO (Kwan and Petersen, 2010)

ThE HEALTh SYSTEM AS A SOCiAL DETERMiNANT OF HEALTh

Inadequate access to essential evidence-based health services is a social determinant of inequalities in health. The concept of inequality and inequity in access to health care is captured by the Inverse Care Law (Hart, 1971), which states that The availability of good medical care tends to vary inversely with the need for it in the population served. Therefore, the health system becomes particularly relevant through the issue of access and good quality care being equitably accessible. The health system has three obligations in confronting inequity: (1) to ensure that resources are distributed among areas in proportion to their relative needs; (2) to respond appropriately to the health care needs of different social groups; and (3) to take the lead in encouraging a wider and more strategic approach to developing healthy public policies at both the national and local levels, to promote equity in health and social justice (CSDH, 2007).

Fig. 1. Determinants of health and policies and strategies to promote social equity in health (Dahlgren and Whitehead, 1993). Reproduced with permission of the authors.

STRATEgiES AND GOALS TO REDUCE INEQUALiTiES iN HEALTh

Strategies to reduce inequalities oscillate between approaches relying on narrowly defined, technology-based medical and public health interventions focused on tackling behavior change through health education and an understanding of health as a social phenomenon requiring intersectoral policies and sometimes linked to a broader social justice agenda (CSDH, 2008). Health policies place too little emphasis on social conditions that promote peoples health and too much emphasis on personal responsibility and medical care (Illich, 1975; Crawford, 1977; McKeown, 1979). There is a case for refocusing upstream away from individuals and groups, who are mistakenly held responsible for their condition, toward a range of broader upstream forces, because many of the problems blamed on individual behaviors are caused mainly by their environments (McKinlay, 1975). Based on the critical re-assessments mentioned above, Dahlgren and Whitehead (1991, 1992, 1993) developed a model of the main determinants of health that shows that overarching societal factors operate through peoples living and working conditions to influence health, both directly and through health behavior (Fig. 1). The Dahlgren and Whitehead model was applied by Barton and Grant (2006) to planning local human habitats. Graham (2004a,b) identified goals ranging from remedying health disadvantages through narrowing health gaps to reducing health gradients. The goal of narrowing health gaps, like remedying health disadvantages, casts health inequalities as a

condition to which only those in disadvantaged circumstances are exposed. Strategies can therefore focus solely on disadvantaged groups, seeking to improve their health in absolute terms (the more limited variant of the goal) and in relative terms. The second goal to narrow health gaps . . . requires a reversal of the trend towards widening health inequalities. To achieve it, the rate of health gain among the poorest groups needs to outstrip that achieved by the comparator group (Graham, 2009). In contrast, the goal of reducing health gradients makes clear that health is unequally distributed not only between the poorest groups and the better-off majority but also across all socio-economic groups. For a broader concept of health inequalities that recognizes that health inequalities follow a social gradient, with the health gap increasing steadily with poorer social class, interventions must therefore reach more than the most deprived, socially excluded populations. This broader framing of health inequalities demands a broader framing of policy goals. Lifting levels of health across the population requires a rate of health gain that is greatest for the poorest, progressively lower for better-off groups and lowest for those in the most advantaged circumstances. Differential rates of health improvement in turn require differential rates of improvement in the factors that promote good health: in what are called the social determinants of health (Graham, 2009). A social determinants strategy gives highest priority to closing the gaps between people at different steps along the social gradient ladder. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism. . . . Greater intensity of action is likely to be needed for those with greater social and economic disadvantage, but focusing solely on the most disadvantaged will not reduce the health gradient, and will only tackle a small part of the problem (Marmot, 2010). There are three levels of public health interventions to improve health of the population:

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(1) Downstream efforts comprise treatments, rehabilitation counseling, and patient education . . . . (McKinlay, 1998). (2) Mid-stream prevention efforts to improve a populations health should involve two main areas: (a) secondary prevention efforts that attempt to modify the risk levels of those individuals and groups who are very likely to experience some untoward outcome; and (b) primary prevention actions to encourage people not to commence risky behaviors that may unnecessarily increase their changes of experiencing a negative health event. (3) Even further upstream are healthy public policy interventions that include governmental, institutional, and organizational actions directed at entire populations. Such interventions require adequate support through tax structures, legal constraints, and reimbursement mechanisms for health promotion and primary prevention (McKinlay, 1998).

Fig. 2. The Health Impact pyramid (Frieden, 2010). Reproduced with permission of the author.

IMpLiCATiONS OF RESEARCh AND POLiCiES ON SOCiAL DETERMiNANTS ON PRiORiTiES FOR RESEARCh ON ORAL HEALTh
The implications of reports such as the CSDH for oral health are profound (CSDH, 2007, 2008). Oral health policy must focus much more attention on the social determinants of oral health and less on dental treatment (Spencer, 2004). The dominant individualistic oral health preventive model alone will not reduce oral health inequalities (Watt, 2007). Since oral diseases have risk factors in common with other chronic diseases, dental researchers need to embed their research and policies with those working on determinants of health inequalities (Watt, 2007). Inequalities in oral health mirror those in general health. The social gradient is consistently found for most common diseases, as well as oral diseases (Adler and Ostrove, 1999; Sanders et al., 2006; Sabbah et al., 2007). If social gradients in general and oral health are universal, then the determinants of the gradients need to be addressed (Watt, 2007). A paradigm shift is needed to one that addresses underlying social determinants of oral health through a combination of complementary public health strategies. The highrisk approach that dominates oral disease prevention focuses attention on high-risk individuals. However, that approach is not directed at underlying causes of disease, so new high-risk individuals will constantly emerge, since conditions creating disease have not been altered. Conversely, in the population approach, the causes of the causes across the whole population are addressed. A range of issues needs to be addressed before significant progress is likely in re-orienting oral health research, practice, and policy toward a social determinants model: (1) A need for closer collaboration and integration of dental health activities with general health approaches. (2) Training of the dental health workforce in a social determinants and population strategy framework (Petersen, 2009). (3) A need also exists for better co-ordination of efforts, both within and between countries.

STRATEgiES TO REDUCE INEQUALiTiES iN ORAL HEALTh

A population approach should be adopted, rather than a highrisk strategy focusing on disadvantaged groups (Batchelor and Sheiham, 2002; Rose et al., 2008). A social determinants approach to reduce inequalities in oral health should be linked to a population approach focused on interventions toward equity and changes in the slope of the gradient, thereby improving health for all using the common risk factor approach. That will require a shift in biomedical research to health promotion research to investigate public health interventions to increase health-enhancing and reducing health-compromising behaviors (Kwan and Petersen, 2010).

ThE HEALTh PROMOTiON AppROACh TO REDUCiNg INEQUALiTiES iN ORAL HEALTh

The health promotion approach involves an environmental perspective. To change peoples behaviors requires a change in their environment (WHO, 2000, 2005b, 2010). Therefore, when priorities for prevention are developed, the health pyramid should be used to prioritize actions (Fig. 2) (Frieden, 2010). Efforts to address socio-economic determinants have the highest priority, followed by public health community-wide enabling interventions that change the context for health by making healthy choices the easier default decisions. Protective interventions with longterm benefits have higher priority than clinic-based prevention, because an environment-based strategy offers greater scope for improvements in oral health than does a strong commitment to individual dental care. However, even the best programs at the pyramids higher levels, dental practice, achieve limited public health impact, largely because of their dependence on an individuals behavioral change over the long term (Frieden, 2010). Therefore, emphasis should be given to policies that make healthy choices the easier choices and health-compromising choices more difficult and socially unacceptable (Milio, 1988).

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The main priority for oral health interventions should be on collaborative enabling research and policies that address the main proximal determinants of oral diseases, sugars, tobacco, hygiene, risky behaviors, and stress. The cornerstone of that approach is the integrated Common Risk Factor Approach (CRFA). The oral health interventions should adopt the principles outlined in the Ottawa Charter, since that is the cornerstone in health promotion (WHO, 1986). This involves changing environmental contexts so that environments make default decisions healthy and health-compromising ones more difficult (Diez-Roux, 1998; Phelan et al., 2004; Frieden, 2010).

are based on the US National Institutes of Health (NIH) Summit recommendations for scientific research on The Science of Eliminating Health Disparities (Dankwa-Mullan et al., 2010). They are included because research should be transdisciplinary and integrative. (1) Intervention research should be designed to address social determinants of oral diseases/conditions both for single strategies and in combination with multiple strategies. The identification of strategies to improve oral health and reduce oral health inequalities within the context of general health is an important first step. The need for research on interventions should be accompanied by measurement of their impact on the social inequality in oral health. Attention should be addressed to changes in distribution of health/ disease resulting from interventions and recognition of the absolute as well as relative preventive benefits from an intervention in sub-groups of the population. There is, however, an important second step that must be added, namely, What is the evidence base that these strategies are indeed effective, feasible, acceptable, affordable, and sustainable in the long term? Similarly, it would be useful to review the essential elements relative to those strategies shown to be effective while, conversely, identifying strategies that have failed and reasons why they failed. (2) Oral diseases and conditions are socially patterned. Emphasis must shift from what is largely basic biomedical and clinical research to community-based determinants of health research. (3) More emphasis is needed to document the social gradient and the absolute and relative risks among individuals and population-attributable risk in the distribution of oral health and disease. A recognition of differential exposure to risk across the social gradient and possible differential effectiveness of interventions on risks by position in the social gradient invites acceptance of the need for universal actions, but with a scale and intensity that are proportionate to the level of disadvantage (proportionate universalism). (4) Broad models of the social determinants of disease need to be explored to increase the range of possible interventions in distribution of risk to oral diseases. Models to explain social gradients in health behaviors and oral health need to adopt a social determinants framework to identify causes of the causes and broaden possibilities for intervention from proximate individual interventions to midstream and upstream population measures. (5) Research on oral health should be incorporated as appropriate into policies for the integrated prevention and treatment of chronic non-communicable and communicable diseases, and into maternal and child health policies. We should look at how to combine forces and leverage our ability to change environmental, cultural, and individual factors through joint effort. (6) Strengthen collaborations among investigators in industrialized, middle-income, and least-developed countries to broaden understanding of strategies, their applicability in operational settings, and explanatory power in various societies.

POLiCiES FOR IMpROviNg ORAL AND DENTAL HEALTh USiNg AN INTEgRATED COMMON RiSk FACTOR AppROACh
Health promotion cannot and should not be compartmentalized to address problems and diseases of specific parts of the body. The dominant approach to general health promotion has focused on actions to reduce specific diseases instead of directing policies to risk factors common to several diseases. The common risk factor approach (CRFA), promoting general health by controlling a small number of risk factors, should have a major impact on numerous common chronic diseases at a lower cost than disease-specific approaches. Oral and general health behaviors co-occur among certain population subgroups. A major benefit of the CRFA is the focus on improving health conditions in general for the whole population and for groups at high risk. It thereby reduces social inequities.

TRANSLATiONAL, TRANSFORMATiONAL, AND TRANSDiSCipLiNARY RESEARCh FOR REDUCiNg HEALTh INEQUALiTiES

Commitment to knowledge translation represents a major opportunity for reduction of health inequalities. Knowledge translation is defined as: the synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving peoples health (WHO, 2005a). A paradigm recommended by the US Governments National Center on Minority Health and Health Disparities is that there should be a shift to integration of translational, transformational, and transdisciplinary research (Dankwa-Mullan et al., 2010). Linking oral health with general health by studying the determinants of the causes causes of causes of oral and general diseases follows the logic of such a shift and should have a higher priority than at present.

RESEARCh TO REDUCE INEQUALiTiES iN HEALTh AND ORAL HEALTh

A research agenda is suggested that will lead to key improvements in global oral health, with particular reference to inequalities among and within countries. The last three recommendations

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(a) policy changes to enhance prevention, (b) provider education consistent with this objective, (c) incentives inherent in financing mechanisms to sustain such service provisions, and (d) self-care incentives to reduce disease and promote health. Linkages between oral health and systemic health strategies should reinforce health system effects. (17) Research is needed on alleviating the unjust inequalities that affect health. Research on inequalities in health should focus on social determinants of health. These determinants include not only health care access, but also the interaction of biological, behavioral, social, environmental, economic, cultural, and political factors. (18) Research on the social determinants of health should strive to address the multiple determinants and social context of the individual, community, or population. (19) Effectively addressing health disparities requires the cultivation of partnerships which can provide a nexus for developing research, strategies, interventions, measures, tools, policies, and institutional shifts that will directly change health care outcomes among vulnerable populations. Therefore, research needs to be collaborative and promote community engagement (Dankwa-Mullan et al., 2010). Translational research and translation of knowledge or science from the molecular or biological level to practical use, including clinical practice and applied technology, are needed: how to move from bench to bedside to curbside. While it is appealing to have an emphasis on translational, transformative, and transdisciplinary research, it is necessary for there to be a constant reminder that this applies at all levels and points in the stream, namely, to sick teeth, sick individuals and sick populations (Baelum and Lopez, 2004).

(7) Pursue more coordinated research to design interventions that enhance both system-related strategies as well as individual-related strategies to positively influence health outcomes, necessitating collaborations among service providers, health policy decision makers/administrators, community educators, commercial entities associated with product development, and mass media. Combined approaches that create and maintain a role and commitment for all parts of the profession are desirable. (8) When searching for possible interventions, more emphasis is needed on socio-economic and environmental factors, as suggested in the Health Impact Pyramid. (9) There are problems of translating evidence into practical interventions, with a lag in moving high-quality evidence into practice moving from bench to bedside to curbside. Research is needed on strategies to close the implementation gap in prevention (primary, secondary, and tertiary) and treatment by getting research findings (distilled systematically as best evidence) into both practice and policy, specifically aimed at tackling inequalities. (10) Research is needed on the problems of lack of an evidence base for various community-based oral health interventions to reduce inequalities in oral health. Establish a database or registry to identify all clinical trials and other types of community-based trials to assist computer searches. Continue to facilitate and update systematic reviews of intervention studies that are designed to reduce oral health inequalities. Disseminate findings regularly to enhance probability of building a systematic body of evidence. (11) Currently, most oral health research is focused on clinical strategies. There is a need to move evidence-based oralhealth approaches into practice, and that requires community-based research involving community participation. Moreover, intercountry exchange of reliable knowledge and experience of community oral-health programs is needed. (12) Targeted research strategies for communities lower down the social gradient should be specifically designed for least-developed countries and underserved community settings to support the proportionate universalism approach (Sheiham, 2008). (13) More research should be conducted to test whether one approach/strategy might be better than another, or whether combined strategies might be appropriate. Reasons for failure to implement, at a population level, measures that have been shown to be effective in clinical or laboratory studies should be analyzed. (14) Interventional strategies, whether focused on changes in health professions education, oral health promotion, or in health systems strengthening, need to measure health outcomes as dependent variables and process-oriented activity as intermediate, qualifying variables. (15) We must assess the extent to which evidence-based approaches are used to incorporate oral health into national policies as appropriate for integrated prevention and control of non-communicable diseases. (16) In strengthening health systems, strategies to be researched should focus on:

ACkNOwLEDgMENTS
The author(s) received no financial support and declared no potential conflicts of interests with respect to the authorship and/ or publication of this article.

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