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 International Journal of Medical Sciences and Pharma Research 

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Review Article                                                          

A Review on Socioeconomic Divide: Implications for Health Outcomes and Oral Health

Panigrahi Priyanca ¹, Satyarup Dharmashree ²*, Nanda Jagruti ¹

¹ Post Graduate Trainee, Department of Public Health Dentistry, Institute of Dental Sciences, Siksha ‘O’ Anusandhan (Deemed to be University), K8, Kalinganagar, Bhubaneswar, Odisha, India 751003.

² Professor and Head, Department of Public Health Dentistry, Institute of Dental Sciences, Siksha ‘O’ Anusandhan (Deemed to be University), K8, Kalinganagar, Bhubaneswar, Odisha, India 751003.

 

 

INTRODUCTION 

In today's society, social inequalities remain a pressing issue affecting individuals from all walks of life. From income and educational disparities to unequal healthcare access, these inequalities have far-reaching consequences on the well-being of individuals and communities¹. Addressing these inequalities and working towards a more equitable future requires a thorough analysis of their root causes and the development of effective strategies to tackle them. These root causes include systemic discrimination, lack of access to resources, and entrenched societal norms that perpetuate inequality². Health inequalities, in particular, are a long-standing issue, with certain populations facing significant disparities in access to healthcare, social determinants of health, and overall health outcomes. By working together, comprehensive strategies can be developed to address the multifaceted nature of social inequalities and create lasting change.³. Only through collective effort and a commitment to social justice can we truly address social inequalities and build a brighter future for generations to come^3,4. The different forms of existing inequality is summarised below in figure.

 

 

Figure 1: Different forms of existing inequality

 

OBJECTIVES 

The objective of the review is to investigate the relationship between socioeconomic status and health outcomes, with a focus on dental health. The review seeks to examine the effects of inequality on public health systems and dental care accessibility by analyzing the worldwide expressions of health disparities brought about by socioeconomic, racial, and geographic variables. Additionally, it aims to provide policy recommendations to close these disparities and advance fair health outcomes globally.

DATA SOURCES 

A thorough search of online databases, with particular emphasis on google was conducted using keywords such as  (((("Social inequality" OR "socioeconomic inequality") AND ("health outcomes" OR "oral health")) AND ("health disparities" OR "health inequities" OR "socioeconomic status")) AND ("access to healthcare" OR "dental care")) OR ("public health" AND "health policy") to retrieve the relevant articles. The selection process involved a manual review of all identified to ensure inclusivity and relevance.

GLOBAL MANIFESTATION OF INEQUALITIES

In 2021, global life expectancy revealed a significant gender gap, with women averaging 73.8 years compared to 68.4 years for men. Despite global efforts to address educational disparities, around 122 million girls and 128 million boys are still out of school worldwide, according to UNICEF. Gender inequality in education is further underscored by the fact that women account for nearly two-thirds of all adults unable to read.⁵

The Under-5 Mortality Rate (U5MR) reflects gendered health disparities, with a higher global rate for females (33 per 1,000 live births) compared to males (31 per 1,000), while the Infant Mortality Rate (IMR) declined to 28 per 1,000 live births in 2020, though significant rural-urban gaps persist. Economic inequality further exacerbates these disparities, as the richest 10% of the global population earn up to 40 times more than the poorest 10%, with the Gini index ranging from 25% in some European countries to over 50% in parts of Latin America and Africa, perpetuating poverty cycles and stalling economic development.^6,7

Global disparities in dental care utilization reveal that individuals in high-income countries are more likely to receive regular dental care, while those in low- and middle-income countries face significant barriers, including cost and availability of services. The World Health Organization (WHO) reports that untreated dental caries affect nearly 3.5 billion people worldwide, with a higher prevalence in disadvantaged populations.⁸

Health disparities are evident in dental care utilization across different regions. In Africa, over 480 million people suffer from oral diseases like dental caries and periodontal diseases, yet oral health remains a low priority, leading to inadequate investment in prevention and care services. The COVID-19 pandemic further disrupted oral health services in the region, with around 90% of countries reporting a complete or partial disruption of services in 2020. The region also faces a severe shortage of dental professionals, with only 3.3 dentists per 100,000 people, compared to the global ratio of 32.8 per 100,000.⁹ In contrast, Japan has a higher utilization of preventive dental care, with 18.6% of the population participating in such visits. Children aged 5 to 9 years had the highest proportion of dental clinic visits, highlighting a focus on preventive care. However, inequalities persist, as preventive dental visits are more common among those with higher socioeconomic status.¹⁰

In the United States, dental services utilization is marked by significant disparities. Women, ethnic majorities, urban residents, and those with higher education, income, or insurance coverage are more likely to utilize dental services. These inequalities are consistent across different populations and have not significantly changed over the past decade.¹¹ Furthermore, social inequalities can erode social cohesion, leading to fragmented communities and increased social tensions.

INEQUALITIES AND HEALTH

Health disparities are a worldwide issue that have a substantial effect on life expectancy and general well-being. The World Health Organization states that differences in access to healthcare, hygienic surroundings, and preventative services might cause life expectancy to differ by 18 to 20 years between high-income and low-income nations. Based on socioeconomic position, there is a clear disparity in health outcomes in India. For instance, the lowest income quintile has an under-five mortality rate that is over 2.5 times greater than the wealthiest ¹². In comparison to metropolitan centers, access to healthcare is often worse in rural regions. Approximately 37% of rural individuals can access inpatient facilities within a 5-kilometer radius, whereas over 60% of residents in urban areas have the same access. This notable discrepancy emphasizes the necessity for focused interventions to bridge the gap in healthcare accessibility and improve health outcomes for disadvantaged populations.¹³ 

The following is the image depicting the health centres in India ¹⁴

Figure 2: Distribution of current status of health centres along with the recommended health centres

INEQUALITIES AND ORAL HEALTH

Globally, oral diseases disproportionately affect the poor and socially disadvantaged populations, highlighting broader health inequalities. Severe gum disease is up to three times more common in lower socio-economic groups, with rural areas in India facing pronounced disparities due to a significant scarcity of dental professionals. Despite over 70% of India's population residing in rural areas, only about 2% of dentists practice there, leading to higher rates of untreated dental decay. Oral health disparities are influenced by social determinants like income, education, and access to care, which impact one's ability to receive preventive treatment ¹⁵. Inequitable access to dental services, including affordability and availability, drives these disparities and affects educational opportunities, employment, and social interactions, leading to stigma and exclusion ¹⁶. In non-industrialized countries, the shortage of dental personnel and urban concentration of services limit access for rural families ¹⁶. In industrialized countries, high treatment costs restrict access to dental care, resulting in better oral health outcomes for higher socioeconomic groups ¹⁷

THEORETICAL EXPLANATIONS OF THE RELATIONSHIP BETWEEN HEALTH AND INEQUALITY 

The concept of health and inequality can be analyzed through various theoretical frameworks, each providing unique insights into the underlying mechanisms. Here is a concise review of these theories, emphasizing their relevance to oral health disparities given by Peterson P.E in 1990.

Natural and Social Selection

 It proposes that healthier individuals are more likely to ascend the social hierarchy, while those with poorer health may descend, creating observed disparities.

Materialist or Structuralist Explanation

It focuses on how socioeconomic status relates to access to essential resources such as food, shelter, and healthcare services.

Dental Perspective

 In non-developing countries, the scarcity of dental professionals and urban concentration of services pose challenges for poor rural families. In nations, high treatment costs limit access, making regular dental visits a privilege of higher socioeconomic classes,

Cultural/Behavioural Explanation

This perspective highlights the role of lifestyle choices in health disparities. People from lower socioeconomic backgrounds often engage in health-damaging behaviours such as poor diet, lack of exercise, and excessive alcohol consumption. ¹⁵

Psychosocial Perspective

Those in lower socioeconomic groups experience greater psychosocial stress, leading to behaviours that damage health. Stress influences health through direct and indirect models, triggering disease development or leading to harmful lifestyle choices.

Dental perspective

Lower socioeconomic groups experience higher psychological stress and anxiety, often leading to increased smoking and unhealthy habits. These behaviours exacerbate oral health inequalities, as stress influences lifestyle choices that negatively impact oral health

Life Course Perspective

The life course perspective asserts that health status at any age results from current conditions and the embodiment of prior living conditions from conception onwards. Health inequalities arise from the interplay of materialist, behavioural, and psychosocial factors over time, as explained by the following models:

           Figure 3: Models of life course perspective

 

 

Figure 4: Accumulation model and critical period model explanation

 

Dental Perspective

Research shows that children from lower socioeconomic backgrounds are more likely to develop dental caries and periodontal disease as adults. This accumulation model highlights the long-term impact of early disadvantages on adult oral health. Understanding various theoretical frameworks helps develop strategies to address health inequalities, especially in oral health, where socioeconomic factors significantly affect access to care and outcomes. Integrating these theories can better target interventions to reduce inequalities and improve health equity.

Artefact Explanation

Health inequalities are artificial constructs resulting from the methods used to measure health and social class. This perspective suggests that observed disparities may not reflect real differences but are instead products of statistical artefacts. ^15,16

PRINCIPLES FOR POLICY ACTION FOR TACKLING SOCIAL INEQUITIES IN HEALTH

Equity

The goal of equity-focused health policy is to reduce or eliminate health disparities that arise from avoidable and unfair factors, rather than to equalize health outcomes completely. Policies should strive to elevate the health of disadvantaged groups to match those who are better off, rather than lowering the health standards of any group.¹⁷

 

 

Figure 5: Approaches to Reducing Social Inequities in Health

 

 

Population Health Policies

Effective population health policies should simultaneously promote overall health gains and reduce health inequities. Reducing health inequities is integral to a comprehensive health development strategy and should be pursued alongside general population health improvements.¹⁸

Social Determinants of Health Inequities

Policies should address the social determinants of health inequities by focusing on the conditions that lead to systematic differences in opportunities, living standards, and lifestyles associated with various social positions.¹⁸

Monitoring and Impact Assessment

It is essential to monitor the differential impacts of health policies to prevent harm. Assessing both relative and absolute changes in social inequities in health provides valuable insights into the magnitude and direction of change.¹⁷

Gender-Specific Analysis

Health inequities should be described and analyzed separately for men and women due to the differing magnitudes and causes of health disparities between the sexes. This gender-specific approach is crucial for developing effective strategies to combat health inequities.¹⁹

 

Ethnic and Geographic Considerations

Analyses of health differences by ethnic background or geography should account for socioeconomic factors, as these differences often vary by social position.¹⁹

Equity-Based Health Systems

Health systems should prioritize equity, ensuring that public health services are not driven by profit and are provided based on need rather than the ability to pay. Health care financing should pool risks across the population, subsidizing high-risk individuals with contributions from low-risk individuals to ensure equitable access to care.

In household survey of the U.S. civilian noninstitutionalized population conducted by Amy E.et al.  examined the urban-rural differences in dental care use among adults aged 18-64, focusing on how demographic characteristics such as location, gender, race, and income level influence dental visitation rates. The research reveals that in 2019, 65.5% of adults aged 18-64 had a dental visit in the past 12 months, with higher rates in urban areas (66.7%) compared to rural areas (57.6%). Women consistently had higher visitation rates than men across both urban and rural settings. Additionally, white adults had higher dental visitation rates than black adults in both regions, with significant differences noted in urban areas²⁰. 

 

GLOBAL INITIATIVE TO REDUCE HEALTH DISPARITIES

Global initiatives to address health inequalities involve extensive collaboration and multi-sectoral strategies among various international organizations. These includes ^21-24:

The United Nations Sustainable Development Goals (SDGs), particularly SDG 3, focus on health and well-being, poverty reduction, education, and environmental sustainability. These goals provide a framework for international efforts to address health inequalities.

The World Health Organization (WHO) collaborates with its 194 member nations to enhance global health through initiatives like the Triple Billion Targets, which aim to achieve better health coverage, emergency protection, and well-being. WHO's regional offices, such as the Pan American Health Organization (PAHO) and the WHO Regional Office for Europe, develop tailored policies to address regional health inequities.

The United Nations Development Programme (UNDP) supports over 170 countries in promoting Universal Health Coverage (UHC) and primary healthcare initiatives. In Ghana, UNDP's backing of the National Health Insurance Scheme (NHIS) and Health Technology Assessments (HTA) helps remove financial barriers to healthcare access. UNDP also collaborates with non-health sectors and leverages digital technology to expand healthcare access.

UNICEF's 2016–2030 Health Strategy focuses on preventing maternal, newborn, and child deaths while promoting health equity. The strategy is supported by the Multiple Indicator Cluster Surveys (MICS), which provide critical data for health interventions.

The International Organization for Migration (IOM) plays a crucial role in ensuring equitable health services for migrants, addressing the unique health challenges faced by this population.

The Organisation for Economic Co-operation and Development (OECD) assists countries in developing high-performing health systems through data analysis and policy guidance, helping to reduce health disparities on a global scale.

Global Health 50/50 advocates for gender equality in health policies, emphasizing the need for equitable health outcomes across genders and supporting the development of gender-sensitive health interventions.

 

The International Union for Health Promotion and Education (IUHPE) is dedicated to promoting global health equity, particularly by focusing on non-communicable diseases and addressing social determinants of health.

NHS England's Long Term Plan targets health disparities by restoring inclusive services, preventing digital exclusion, and improving data accuracy. The National Healthcare Inequalities Improvement Programme (HiQiP) and the Core20PLUS5 framework focus on improving health outcomes for specific populations and clinical areas. Collaborations with organizations like the NHS Race and Health Observatory are part of international efforts to address health inequalities.

These global initiatives reflect a comprehensive approach to reducing health disparities and improving health outcomes worldwide through collaborative efforts and innovative strategies.

INDIAN GOVERNMENT INIATIVES FOR REDUCING INEQUALITIES

The Indian government has addressed economic, social, health, educational, and environmental inequalities through various initiatives. For Economic disparities it has been tackled with various schemes like^25,26,27

The Indian government addresses economic disparities through the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA), which provides jobs to over 90 million households annually.

The Pradhan Mantri Awas Yojana (PMAY) has been instrumental in constructing over 33 million houses, contributing significantly to reducing housing inequality.

Direct Benefit Transfers (DBT) have effectively delivered INR 3.7 lakh crore to 1.5 billion beneficiaries, ensuring that financial support reaches those in need.

The Pradhan Mantri Jan Dhan Yojana (PMJDY) has successfully opened over 46 crore   bank accounts, enhancing financial inclusion across the country.

For Health Initiatives:

In the health sector, Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) has enrolled over 50 crore beneficiaries, providing essential healthcare services.

The National Health Mission (NHM) has played a critical role in reducing maternal mortality rates from 174 to 113 per 100,000 live births between 2013-15 and 2019-21.

The Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) has established 22 new AIIMS-like institutions, improving access to advanced medical care.

For Educational Initiatives:

The Right to Education Act (RTE) has significantly increased school enrollment rates to over 96% for children aged 6 to 14 years, supported by scholarships.

Gender Initiatives

Gender-focused initiatives have improved the child sex ratio from 919 to 929 girls per 1,000 boys.

The Pradhan Mantri Matru Vandana Yojana (PMMVY) has provided support to over 1.5 crore pregnant and lactating mothers.

Environmental Initiatives

The Swachh Bharat Mission has built over 11 crore toilets, significantly improving sanitation across India.

The National Clean Air Programme (NCAP) aims to reduce air pollution by 20-30% by 2024, addressing environmental concerns.

The Pradhan Mantri Gram Sadak Yojana (PMGSY) has constructed over 6.2 lakh kilometers of all-weather roads, improving rural connectivity.

The Deendayal Antyodaya Yojana – National Rural Livelihoods Mission (DAY-NRLM) has facilitated over 60 lakh self-help groups, promoting self-employment and skill development

CONCLUSION 

An increasing number of nations are attempting to address the issue of socioeconomic disparities in health and are determining what workable steps may be done domestically to make improvements. The goal ought to be to assist in advancing a shared comprehension of the ideas and precepts that serve as the foundation for policies aimed at addressing health disparities. 

Public health has a vital and diverse role in addressing socioeconomic inequality. Public health efforts have the potential to greatly reduce health inequalities by addressing both the specific health needs and the wider socioeconomic determinants of health. This all-encompassing strategy not only enhances the health of the person and the community, but it also helps to stabilize the economy and improve the standard of living for all members of society. 

Acknowledgement: I would like to express my sincere gratitude to Dr. Dharmashree Satyarup and Dr. Jagruti Nanda for their invaluable assistance in collecting and organizing the materials essential for this work. Their meticulous efforts in sorting the information have greatly contributed to the success of the manuscript 

Author Contributions: All the authors equally contributed to this work.

Source of Support: Nil

Funding: The authors declared that this study has received no financial support.

Data Availability Statement: The data presented in this study are available on request from the corresponding author. 

Ethics approval and consent to participate: Not applicable

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