**Tackling oral health inequities — population level**
EQUALITY
EQUITY
REALITY
Image source: https://belonging.berkeley.edu/equity-vs-equality-whats-difference
- Equality
- Equity
- Reality
*Image source: https://belonging.berkeley.edu/equity-vs-equality-whats-difference*
![]()
This labelled diagram illustrates the concepts of equality, equity, and reality using three panels of spectators attempting to watch a baseball game over a fence. The section labeled 'EQUALITY' shows individuals of different heights standing on identical boxes, resulting in unequal visibility, whereas 'EQUITY' shows boxes distributed based on need to ensure equal visibility for all. The 'REALITY' panel depicts a systemic imbalance where the tallest person stands on a large stack of boxes while the shortest person remains in a hole, unable to see.
6a. Understanding approaches to tackle oral health inequities - population level
“Upstream” and “Downstream approach” – McKinlay 1979
Figure 20.2 The concept of upstream and downstream approaches to oral health improvement
Big business
Manufacturers of illness
Upstream
Clinical Dentistry-Health Education
Downstream
Source: Ivor G Chestnutt, Dental Public Health at a Glance, John Wiley & Sons, Inc., 2016.
---
Understanding approaches to tackle oral health inequities at the population level involves the "upstream" and "downstream" framework (McKinlay 1979).
#### The Upstream–Downstream Continuum
- **Upstream:** Focuses on "big business" and the manufacturers of illness.
- **Downstream:** Focuses on clinical dentistry and health education.
Figure 20.2: The concept of upstream and downstream approaches to oral health improvement.
*Source: Ivor G Chestnutt, Dental Public Health at a Glance, John Wiley & Sons, Inc., 2016.*
![]()
This labelled diagram illustrates the concept of upstream and downstream approaches to oral health improvement using a river metaphor where 'Big business' and 'Manufacturers of illness' are positioned at the source (upstream) releasing harmful products, while 'Clinical Dentistry-Health Education' is depicted treating individuals further down the flow (downstream). The figure visually contrasts addressing root causes of disease at the top of the stream versus managing the consequences among the population at the bottom.
‘Upstream’
Healthy public policy
National &/or local policy initiatives
Legislation/regulation
Fiscal measures
Healthy settings-HPS
Community development
Training other professional groups
Media campaigns
School dental health education
Chair side dental health education
Clinical prevention
‘Downstream’
Health education and clinical prevention
**Figure 8.4** Upstream action.
Watt, R.G. (2007). From victim blaming to upstream action: tackling the social determinants of oral health inequalities. *Community Dentistry and Oral Epidemiology* **35**, 1–11.
#### Continuum of Action: From Upstream to Downstream
- **Upstream (Healthy public policy):**
- National and/or local policy initiatives
- Legislation/regulation
- Fiscal measures
- Healthy settings (HPS)
- Community development
- Training other professional groups
- Media campaigns
- School dental health education
- Chairside dental health education
- Clinical prevention
- **Downstream (Health education and clinical prevention)**
Figure 8.4: Upstream action.
*Watt, R.G. (2007). From victim blaming to upstream action: tackling the social determinants of oral health inequalities, Community Dentistry and Oral Epidemiology, 35, 1–11.*
![]()
Labelled diagram: A diagonal arrow pointing from bottom-right ('Downstream') to top-left ('Upstream'), with dotted arrows pointing to the main arrow from a list of interventions. The slide text identifies the upstream end as 'Healthy public policy' and the downstream end as 'Health education and clinical prevention'.
# 6b. Managing oral health inequalities/inequities:
*Population health framework: Ottawa Charter for oral health promotion*
*The Ottawa Charter’s emblem.*
**STRENGTHEN COMMUNITY ACTION**
*RENFORCER L’ACTION COMMUNAUTAIRE*
**DEVELOP PERSONAL SKILLS**
*DÉVELOPPER LES APTITUDES PERSONNELLES*
**ENABLE**
*CONFÉRER LES MOYENS*
**MEDIATE**
*SERVIR DE MÉDIATEUR*
**ADVOCATE**
*PROMOUVOIR L’IDÉE*
**CREATE SUPPORTIVE ENVIRONMENTS**
**CRÉER DES MILIEUX FAVORABLES**
**BUILD HEALTHY PUBLIC POLICY**
**REORIENT HEALTH SERVICES**
*RÉORIENTER LES SERVICES DE SANTÉ*
**ÉTABLIR UNE POLITIQUE PUBLIQUE Saine**
- Health promotion is the process of enabling people to increase control over, and to improve, their health.
- It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions (WHO)
Image source: https://bsahely.com/2018/09/12/the-ottawa-charter-for-health-promotion-who-1986/
David Locker, Evelyn Wexler, Lone Schou. Principles of oral health promotion, Chapter 11, Community Oral Health, Quintessence books, pages:303-4
The emblem contains signs of an enhancement of the individual by health promotion. The feel is also to empower individuals to enable them to ask to enable them to ask for health to be a source of happiness. The need is to emphasize the need to enable health as a part of life. It is a need to move away from a focus on individual behaviour towards a wide range of social and environmental interventions (WHO).
#### Core Principles and Action Areas of the Ottawa Charter
*The Ottawa Charter Emblem:*
- **Advocate** (*Promouvoir l’idée*)
- **Enable** (*Conférer les moyens*)
- **Mediate** (*Servir de médiateur*)
**Five Key Action Areas:**
- **Build Healthy Public Policy** (*Établir une politique publique saine*)
- **Create Supportive Environments** (*Créer des milieux favorables*)
- **Strengthen Community Action** (*Renforcer l’action communautaire*)
- **Develop Personal Skills** (*Développer les aptitudes personnelles*)
- **Reorient Health Services** (*Réorienter les services de santé*)
#### Definition and Scope of Health Promotion
- Health promotion is the process of enabling people to increase control over, and to improve, their health.
- It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions (WHO).
The emblem symbolizes the enhancement and empowerment of individuals through health promotion, enabling them to pursue health as a resource for life and well-being. It underscores the vital shift from solely targeting individual lifestyle factors to addressing broader social and environmental determinants.
*David Locker, Evelyn Wexler, Lone Schou. Principles of oral health promotion, Chapter 11, Community Oral Health, Quintessence books, pages:303-4.*
> [!note] Lecturer — Downstream Inequities
> Most clinical dental activity occurs downstream, after oral disease has developed.
>
> > - It benefits people who are able to attend dental services, while people with substantial needs who do not attend remain unserved.
> > - Action is delayed until disease has developed, and access to the benefits of care is not equally distributed.
> > - Relying primarily on downstream services may therefore worsen inequalities.
> [!note] Lecturer — Upstream Equity
> The further upstream action occurs, the more equitable it can be because policies and conditions apply to everyone in the relevant community or population.
> [!note] Lecturer — Combining Approaches
> The solution to dental problems is not simply to increase the number of dentists.
>
> > - An exclusive focus on the biomedical model can result in funding specialised hospitals and disease-focused services, which primarily addresses downstream problems.
> > - The best approach to tackling inequity combines upstream action through healthy public policy and health promotion with downstream action through accessible dental services.
> > - Combining both approaches addresses current needs while reducing future disease.
> [!note] Lecturer — Ottawa Charter Origins
> The Ottawa Charter was introduced and adopted at the First International Conference on Health Promotion in Ottawa in 1986. It provides a framework for planning health promotion programs.
>
> - The framework supports systematic, uniform and efficient implementation.
> - It directs strategies towards the major areas required to improve population health and can also be applied to oral health promotion.
> [!note] Lecturer — Community Action
> Improving oral health requires community engagement rather than implementing policies without approval, consultation or involvement.
>
> - Programs may involve Aboriginal communities, migrant or refugee community leaders, and steering committees led by community representatives.
> - Recognising that cultures and communities work differently helps ensure programs are appropriate, accepted and effective.
> [!note] Lecturer — Personal Skills
> Developing personal skills includes providing people with knowledge and skills that support healthy behaviour.
>
> - Examples include teaching toothbrushing, flossing and the use of interdental aids.
> - Aged-care workers may be taught how to clean residents’ dentures, and people may need education about oral hygiene practices with which they are unfamiliar.
> [!note] Lecturer — Supportive Environments
> A residential aged-care setting should function as an oral-health-promoting environment.
>
> - This may include pamphlets, oral health resources and support for oral hygiene.
> - Such measures can help reduce preventable hospitalisations among frail and elderly residents susceptible to dental conditions.
> [!note] Lecturer — Reorienting Services
> Reorienting health services means moving away from primarily disease-centred care towards more promotive practices.
>
> - This may involve community oral health services, maximising efficiency with limited resources, and using artificial intelligence and computers.
> - Services can also train a broader workforce in social medicine concepts while using teledentistry to reach remote areas.
> [!note] Lecturer — Public Policy
> Healthy public policy holds the other action areas together. Community action, personal skills, supportive environments and reoriented services will not function effectively without strong public policy.
>
> - Policy must evolve as communities and populations change; a policy developed in the 1990s may not remain viable in the 2000s.
> [!note] Lecturer — Health Promotion Scope
> Health promotion is broader than health education. Educating a person without changing the surrounding environment may not improve oral health outcomes, because people need conditions that allow them to adopt and maintain healthy behaviours.
![]()
This figure is a labelled diagram of the Ottawa Charter's emblem, featuring a central circle and swirling segments enclosed by a red ring. The center lists the core functions 'ENABLE / CONFÉRER LES MOYENS', 'MEDIATE / SERVIR DE MÉDIATEUR', and 'ADVOCATE / PROMOUVOIR L'IDÉE', while the surrounding blue shapes represent 'STRENGTHEN COMMUNITY ACTION', 'DEVELOP PERSONAL SKILLS', 'CREATE SUPPORTIVE ENVIRONMENTS', and 'REORIENT HEALTH SERVICES' (all with French translations). The outer red ring displays the text 'BUILD HEALTHY PUBLIC POLICY' and 'ÉTABLIR UNE POLITIQUE PUBLIQUE SAINE'.
# Common risk factor approach in dental public health
**Figure 21.1 Common-risk factor approach.** Source: *Watt 2005. Reproduced with permission from World Health Organisation. Originally adapted from Sheiham and Watt 2000 with permission from John Wiley & Sons.*
```mermaid
graph LR
subgraph Risk_Factors_Left [Risk factors]
Diet
Stress
Control
Hygiene
end
subgraph Disease [Disease]
Obesity
Cancer
Heart_disease[Heart disease]
Respiratory_disease[Respiratory disease]
Dental_caries[Dental caries]
Periodontal_diseases[Periodontal diseases]
Trauma
end
subgraph Risk_Factors_Right [Risk factors]
Tobacco
Alcohol
Exercise
Injuries
end
Diet --> Obesity
Diet --> Cancer
Diet --> Heart_disease
Diet --> Dental_caries
Stress --> Heart_disease
Stress --> Periodontal_diseases
Control --> Heart_disease
Control --> Periodontal_diseases
Hygiene --> Periodontal_diseases
Tobacco --> Cancer
Tobacco --> Heart_disease
Tobacco --> Respiratory_disease
Tobacco --> Periodontal_diseases
Alcohol --> Cancer
Alcohol --> Heart_disease
Alcohol --> Trauma
Exercise --> Heart_disease
Exercise --> Obesity
Injuries --> Trauma
```
*Environmental Influences / Context:*
- Left: School, Policy
- Bottom: Political environment, Physical environment, Social environment
- Right: Workplace, Housing
*Source: Ivor G Chestnutt, Dental Public Health at a Glance, John Wiley & Sons, Inc., 2016.*
#### Framework Overview
**Figure 21.1: Common-risk factor approach**
```mermaid
graph LR
subgraph Risk_Factors_Left [Risk factors]
Diet
Stress
Control
Hygiene
end
subgraph Disease [Disease]
Obesity
Cancer
Heart_disease[Heart disease]
Respiratory_disease[Respiratory disease]
Dental_caries[Dental caries]
Periodontal_diseases[Periodontal diseases]
Trauma
end
subgraph Risk_Factors_Right [Risk factors]
Tobacco
Alcohol
Exercise
Injuries
end
Diet --> Obesity
Diet --> Cancer
Diet --> Heart_disease
Diet --> Dental_caries
Stress --> Heart_disease
Stress --> Periodontal_diseases
Control --> Heart_disease
Control --> Periodontal_diseases
Hygiene --> Periodontal_diseases
Tobacco --> Cancer
Tobacco --> Heart_disease
Tobacco --> Respiratory_disease
Tobacco --> Periodontal_diseases
Alcohol --> Cancer
Alcohol --> Heart_disease
Alcohol --> Trauma
Exercise --> Heart_disease
Exercise --> Obesity
Injuries --> Trauma
```
**Environmental Influences and Context:**
- **Social & Structural:** School, Policy, Workplace, Housing
- **Broad Environments:** Political environment, Physical environment, Social environment
*Watt 2005. Reproduced with permission from World Health Organisation. Originally adapted from Sheiham and Watt 2000 with permission from John Wiley & Sons.*
*Ivor G Chestnutt, Dental Public Health at a Glance, John Wiley & Sons, Inc., 2016.*
> [!example] Processed Food and Health
> People with dental caries who consume large amounts of processed food may also experience obesity. Processed food may be cheaper, making it more common among people who are poor; this demonstrates a link between poor oral health and general health.
![]()
This labelled diagram illustrates the common-risk factor approach, featuring three vertical columns where 'Risk factors' on the left (Diet, Stress, Control, Hygiene) and right (Tobacco, Alcohol, Exercise, Injuries) are linked via arrows to a central 'Disease' column containing conditions like Obesity, Cancer, Heart disease, Respiratory disease, Dental caries, Periodontal diseases, and Trauma. Surrounding the core model are arrows representing environmental influences pointing inward from 'School', 'Policy', 'Workplace', 'Housing', and the 'Political', 'Physical', and 'Social' environments.
# 6b. Managing oral health inequalities/inequities:
## Population health framework: Using principles of Ottawa Charter for oral health promotion
| Principles of Ottawa charter | Actions to reduce oral health inequities |
| :--- | :--- |
| Building healthy public policy | National and Local food policies |
| | Water Fluoridation, Smoking, Paan, Alcohol policy |
| Creating supportive environments | Supporting healthy supermarket practice and promoting sponsorship ethics |
| | Providing access to more fluoridated toothpastes |
| | Oral health promoting schools |
| Developing personal skills | Oral health education – workplace or school based. |
| Strengthening community action | Community development, engagement and representation. |
| Reorienting health services | Accessible primary dental care services in remote settings and priority populations, training the broader workforce, using tele dentistry, encouraging sugar free prescriptions and focussing on improving research data. |
<br>
Source: Watt, R., Sheiham, A. Inequalities in oral health: a review of the evidence and recommendations for action. *Br Dent J* **187**, 6–12 (1999).
| Principles of Ottawa Charter | Actions to Reduce Oral Health Inequities |
| :--- | :--- |
| **Building healthy public policy** | - National and local food policies<br>- Water fluoridation, smoking, paan, and alcohol policies |
| **Creating supportive environments** | - Supporting healthy supermarket practice and promoting sponsorship ethics<br>- Providing access to more fluoridated toothpastes<br>- Oral health promoting schools |
| **Developing personal skills** | - Oral health education (workplace- or school-based) |
| **Strengthening community action** | - Community development, engagement, and representation |
| **Reorienting health services** | - Accessible primary dental care services in remote settings and priority populations<br>- Training the broader workforce<br>- Utilizing teledentistry<br>- Encouraging sugar-free prescriptions<br>- Improving research data |
*Watt, R., Sheiham, A. (1999). Inequalities in oral health: a review of the evidence and recommendations for action, British Dental Journal, 187, 6–12.*
> [!note] Lecturer — Public Policy Measures
> Additional policy measures include using taxation to make cigarettes more expensive and difficult to purchase, introducing sugar taxes as macroeconomic policies, and increasing the cost of sugar-related products. The Australian Medical Association has recommended applying such policies to soft drinks.
> [!note] Lecturer — Supportive Environments
> Supportive environments can reduce the placement of chocolates and other products near checkout counters, where they may tempt customers to purchase them.
> [!note] Lecturer — Upstream Health Promotion
> Health promotion is an upstream approach. The more action occurs upstream, the greater the opportunity to tackle inequalities.
**6c.** Understanding approaches to tackle oral health inequities – **the National Oral Health Plan (2015-24)**
**NATIONAL GOALS**
Improve oral health status by reducing the incidence, prevalence and effects of oral disease
Reduce inequalities in oral health status across the Australian population
**GUIDING PRINCIPLES**
Population health approach
Proportionate universalism
Appropriate and accessible services
Integrated oral and general health
Source: Government of Australia. Healthy Mouths Healthy Lives – AUSTRALIA'S NATIONAL ORAL HEALTH PLAN 2015 – 2024. Adelaide; 2016.
#### National Goals
- Improve oral health status by reducing the incidence, prevalence and effects of oral disease
- Reduce inequalities in oral health status across the Australian population
#### Guiding Principles
- Population health approach
- Proportionate universalism
- Appropriate and accessible services
- Integrated oral and general health
*Government of Australia. Healthy Mouths Healthy Lives – AUSTRALIA'S NATIONAL ORAL HEALTH PLAN 2015 – 2024. Adelaide; 2016.*
> [!note] Lecturer — Population-Level Approaches
> The national plan demonstrates how inequity can be addressed through population-level oral health programs.
>
> > - Whole population approaches work across the entire population.
> > - Targeted population approaches focus on specific populations.
> > - High-risk approaches focus on people at high risk.
> > - Proportionate universalism allocates resources according to the proportion of disease burden.
> [!note] Lecturer — Proportionate Universalism
> Proportionate universalism is an evidence-based way to use limited resources according to need.
>
> > - More resources should be directed towards populations with greater need.
> > - Funding should be allocated in proportion to the burden of disease.
> > - The burden of oral disease is disproportionate, particularly among priority populations.
> [!note] Lecturer — Current Oral Health Data
> Existing oral health data are old, so further research is needed to understand current oral disease problems.
>
> > - A Senate committee suggested conducting further research, and the government agreed.
> > - Another national oral health survey would help identify current oral disease problems.
> > - Understanding the problems is necessary before they can be addressed.
> [!note] Lecturer — Equitable Resource Allocation
> An equitable national approach requires resources to be proportionate to the burden of disease. Priority populations should receive more funding because they experience a greater burden of oral disease.
>
> > - The approach combines universal population-level action, targeted action for particular populations and high-risk interventions.
> > - It also combines proportionate resource allocation, upstream health promotion, downstream access to care, workforce development, and research evidence.
6c. Understanding approaches to tackle oral health inequities – the National Oral Health Plan (2015-24) – Universal approach
| Foundation Areas |
| :--- |
| **Oral health promotion**<br>All Australians have access to oral health promoting environments and appropriate evidence-based information and programs that support them to make informed decisions about their oral health |
| **Accessible oral health services**<br>All Australians have access to appropriate oral health care in a clinically acceptable timeframe |
| **System alignment and integration**<br>Social, health and education systems work together to support healthy mouths and healthy lives |
| **Safety and quality**<br>Oral health services are provided in accordance with the Australian Safety and Quality Goals for Health Care |
| **Workforce development**<br>The workforce for oral health is of an appropriate composition and size and is appropriately trained and distributed |
| **Research and evaluation**<br>Appropriate and timely data is available at both the population and service level for planning, monitoring and evaluation |
Source: Government of Australia. Healthy Mouths Healthy Lives - AUSTRALIA'S NATIONAL ORAL HEALTH PLAN 2015 - 2024. Adelaide; 2016.
#### Foundation Areas
- **Oral health promotion**: All Australians have access to oral health promoting environments and appropriate evidence-based information and programs that support them to make informed decisions about their oral health.
- **Accessible oral health services**: All Australians have access to appropriate oral health care in a clinically acceptable timeframe.
- **System alignment and integration**: Social, health and education systems work together to support healthy mouths and healthy lives.
- **Safety and quality**: Oral health services are provided in accordance with the Australian Safety and Quality Goals for Health Care.
- **Workforce development**: The workforce for oral health is of an appropriate composition and size and is appropriately trained and distributed.
- **Research and evaluation**: Appropriate and timely data is available at both the population and service level for planning, monitoring and evaluation.
*Government of Australia. Healthy Mouths Healthy Lives - AUSTRALIA'S NATIONAL ORAL HEALTH PLAN 2015 - 2024. Adelaide; 2016.*
6c. Understanding approaches to tackle oral health inequities – the National Oral Health Plan (2015-24) – Equitable approach
Government of Australia. Healthy Mouths Healthy Lives - Australia's National Oral Health Plan 2015-2024. Adelaide; 2016.
*Government of Australia. Healthy Mouths Healthy Lives - Australia's National Oral Health Plan 2015-2024. Adelaide; 2016.*
# Lets revise..
1. **Upstream and downstream approach.**
2. **Health promotion and Ottawa charter**
3. **Common risk factor approach whilst developing population activities**
4. **National oral health plan in Australia.**
### Key Concepts for Revision
1. Upstream and downstream approach
2. Health promotion and Ottawa charter
3. Common risk factor approach whilst developing population activities
4. National oral health plan in Australia
> [!note] Lecturer — Equity and Inequality
> Equity, rather than equality, is the goal of population-level action.
>
> > - Downstream services alone cannot address oral health inequalities because they primarily benefit people who can access dental care.
> > - Upstream action occurs before disease develops and can benefit everyone in a population.
> > - The most effective and sustainable programs combine upstream and downstream approaches.
![]()
Clipart illustration of an open book with a blue ribbon bookmark and a fountain pen resting beside it.
![]()
Cartoon illustration of a boy with brown hair and a white shirt reading a blue book at a desk, serving as a visual metaphor for the 'Lets revise..' topic listed on the slide.
![]()
Illustration: A cartoon orange cat with blue eyes reading an open book.
[^1]: Original PDF page 1: [[L4.1 Tackling Oral health inequalities at the population Level_slides.pdf#page=1|L4.1 Tackling Oral health inequalities at the population Level slides, p.1]]
[^2]: Original PDF page 2: [[L4.1 Tackling Oral health inequalities at the population Level_slides.pdf#page=2|L4.1 Tackling Oral health inequalities at the population Level slides, p.2]]
[^3]: Original PDF page 3: [[L4.1 Tackling Oral health inequalities at the population Level_slides.pdf#page=3|L4.1 Tackling Oral health inequalities at the population Level slides, p.3]]
[^4]: Original PDF page 4: [[L4.1 Tackling Oral health inequalities at the population Level_slides.pdf#page=4|L4.1 Tackling Oral health inequalities at the population Level slides, p.4]]
[^5]: Original PDF page 5: [[L4.1 Tackling Oral health inequalities at the population Level_slides.pdf#page=5|L4.1 Tackling Oral health inequalities at the population Level slides, p.5]]
[^6]: Original PDF page 6: [[L4.1 Tackling Oral health inequalities at the population Level_slides.pdf#page=6|L4.1 Tackling Oral health inequalities at the population Level slides, p.6]]
[^7]: Original PDF page 7: [[L4.1 Tackling Oral health inequalities at the population Level_slides.pdf#page=7|L4.1 Tackling Oral health inequalities at the population Level slides, p.7]]
[^8]: Original PDF page 8: [[L4.1 Tackling Oral health inequalities at the population Level_slides.pdf#page=8|L4.1 Tackling Oral health inequalities at the population Level slides, p.8]]
[^9]: Original PDF page 9: [[L4.1 Tackling Oral health inequalities at the population Level_slides.pdf#page=9|L4.1 Tackling Oral health inequalities at the population Level slides, p.9]]
[^10]: Original PDF page 10: [[L4.1 Tackling Oral health inequalities at the population Level_slides.pdf#page=10|L4.1 Tackling Oral health inequalities at the population Level slides, p.10]]
[^11]: Original PDF page 11: [[L4.1 Tackling Oral health inequalities at the population Level_slides.pdf#page=11|L4.1 Tackling Oral health inequalities at the population Level slides, p.11]]