Oral health inequalities: the view through welfare state regimes

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1 Oral health inequalities: the view through welfare state regimes Georgios Tsakos Dept. of Epidemiology and Public Health, UCL Berlin, 15 th May 2017

2 Why do welfare states matter for health? 1. Welfare states affect social policies (e.g. education, income support, access to healthy foods), and these in turn influence distribution of resources relevant for health 2. Health care systems are organised and reformed according to social policies and political institutions 3. Social organisation of welfare states (socioeconomic and political context) affects psychosocial factors (social cohesion, interpersonal trust and sense of belonging), which in turn affect health

3 Policies can make a difference. even unintentionally Inequalities increased less in countries with more protective labour market policies and higher social spending Leinsalu M, Stirbu I, Vagero D, et al., Educational inequalities in mortality in four European countries; divergence in trends during the post-communist transition from 1990 to Int J Epidemiol, 2009; 38:

4 CSDH conceptual framework for action on the social determinants of health Solar O, Irwin A (2010): A Conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Geneva: World Health Organization.

5 Why are international comparisons in health inequalities important? Study political determinants of health inequalities 1 Understand contexts where socioeconomic inequalities are generated in the first place 2 Identify how socioeconomic changes affect health inequalities Understand how societal institutional structures influence health inequalities and identify opportunities for reducing inequalities 3 1. Muntaner C, Borrell C, Ng E et al. Politics, welfare regimes, and population health: controversies and evidence. Sociol Health Illn. 2011; 33: Brennestuhl S, Quesnel-Vallee A, McDonough P. Welfare regimes, population health and health inequalities: a research synthesis, J Epidemiol Community Health 2012; 66: , 3. Mackenbach JP, Stirbu I, Roskam A-JR et al. Socioeconomic inequalities in health in 22 European countries. N Eng J Med 2008; 358:

6 Putting context in international health comparisons: welfare state theories Health inequalities and political factors (e.g. different welfare state regimes) Welfare state? Role played by the state in social services and benefits such as education, health, housing, poverty relief, among others 1. The combination of market, state, and family in providing goods and services within a country Bambra C, Fox D, Scott-Samuel A. A politics of health glossary, J Epidemiol Community Health 2007; 61: Chung H, Muntaner C., Welfare state matters: a typological analysis of wealthy countries. Health Policy 2007; 80:

7 Typologies of welfare state regimes According to Esping-Andersen (1990) Liberal Conservative Socialdemocratic Most welfare goods and services are left to the market Key role of family and certain earningsrelated welfare benefits provided by state Universal and comprehensive benefits provided by state, high redistributive impact Esping-Andersen G. The three worlds of welfare state capitalism. Polity Press; Cambridge: 1990.

8 Welfare states: Liberal, Conservative, Social-democratic Source: O Mara M, Based on: Arts W, Gelissen J. Three worlds of welfare capitalism or more? A state-of-the-art report. J Eur Soc Policy 2002, 12:

9 Typologies of welfare state regimes According to Ferrera (1996) Southern Fragmented welfare benefits: generosity in certain provisions and weak in others, marked mix publicprivate in benefits and services, and corruption in the distribution of cash subsidies Anglo-Saxon Bismarckian Scandinavian Southern Ferrera M. The southern model of welfare in social Europe. J Eur Soc Policy, 1996; 6:17-37.

10 Typologies of welfare state regimes More recently, the Eastern European welfare state type has also been considered in the social policy literature Eastern Countries that experienced the dramatic changes from a communist welfare state to marketization and decentralisation Czech Republic, Estonia, Hungary, Poland, Slovakia, and Slovenia

11 Welfare state regimes in Europe: (Ferrera s typology) + Eastern Anglo-Saxon Bismarckian Scandinavian Southern Eastern Ferrera M. The southern model of welfare in social Europe. J Eur Soc Policy, 1996; 6:17-37.

12 Welfare state types: Ferrera s typology + Eastern Scandinavian Anglo-Saxon Bismarckian Southern Eastern Sweden UK Austria Greece Czech Rep. Finland Ireland Belgium Italy Estonia Denmark France Portugal Hungary Germany Spain Poland Luxemburg Slovakia Netherlands Slovenia

13 Health (inequalities) and welfare states: summary of evidence Better population health in social democratic welfare regimes (those with more generous and universal welfare provisions) 1 Considerable cross-national variation in social and behavioural determinants of health across European countries 2 Inconclusive evidence of lower health inequalities in stronger welfare states 3 1. Navarro et al, 2003; Navarro V, Muntaner C, Borrell C et al, 2006; Chung and Muntaner, 2006; Muntaner et al, Huijts, Stornes, Eikemo et al, Dahl et al, 2006; Beckfield and Krieger, 2009; Muntaner et al, 2011; Brennenstuhl et al, 2012

14 Oral health status by welfare state Age-standardized prevalence of edentulousness by welfare state regime Scandinavian Anglo-Saxon Bismarckian Southern Eastern Guarnizo-Herreno CC, Tsakos G, Sheiham A, Watt RG. Eur J Oral Sci 2013; 121:

15 Oral health status by welfare state Age-standardized prevalence of no functional dentition by 70 welfare state regime it seems to be good to live in Scandinavia but not so much in Eastern Europe Scandinavian Anglo-Saxon Bismarckian Southern Eastern Guarnizo-Herreno CC, Tsakos G, Sheiham A, Watt RG. Eur J Oral Sci 2013; 121:

16 Oral health related quality of life by welfare state Age-standardized prevalence of 1 oral impact on daily life but perceptions about quality of life is a different matter Scandinavian Anglo-Saxon Bismarckian Southern Eastern Guarnizo-Herreno CC, Tsakos G, Sheiham A, Watt RG. Eur J Oral Sci 2013; 121:

17 Oral health inequalities by welfare state Age-standardized prevalence of edentulousness by occupation and welfare state regime Managers and professionals Intermediate Manual workers * P for trend 0.01 Clear gradients everywhere. * * * * * 5 0 Scandinavian Anglo-Saxon Bismarckian Southern Eastern Guarnizo-Herreño CC, Watt RG, Pikhart H, Sheiham A, Tsakos G. J Epidemiol Community Health. 2013;67:

18 Oral health inequalities by welfare state Age-standardized prevalence of no functional dentition by education level and welfare state regime years and older years Up to 15 years 80 * * P for trend 0.01 * And again Social gradients * * * 20 0 Scandinavian Anglo-Saxon Bismarckian Southern Eastern Guarnizo-Herreño CC, Watt RG, Pikhart H, Sheiham A, Tsakos G. J Epidemiol Commuity Health. 2013;67:

19 Oral health inequalities by welfare state Age-standardized 20 years older prevalence years of Up 1 to oral 15 years impact on daily life by education level and welfare state regime * * * * * 10 0 Scandinavian Anglo-Saxon Bismarckian Southern Eastern * P for trend 0.01 but not equally for quality of life.. Guarnizo-Herreño CC, Watt RG, Pikhart H, Sheiham A, Tsakos G. Community Dent Oral Epidemiol. 2014;42:

20 Household income gradients in quality of life for dentate adults in four countries - Smaller inequalities in Germany (pensions and sickness cash benefits have universal coverage and earnings-related benefits) - Larger inequalities in Australia (benefits are means-tested, and the coverage is limited to the low-income part of the population) Sanders AE, Slade GD, John MT, Steele JG, Suominen-Taipale AL, Lahti S, Nuttall NM, Allen PF. A cross-national comparison of income gradients in oral health quality of life in four welfare states: application of the Korpi and Palme typology. J Epidemiol Community Health. 2009;63:

21 No functional dentition: relative inequalities by welfare state Welfare State Type Socioeconomic position measure Education Occupational class Subjective social status RII 95% CI RII 95% CI RII 95% CI Scandinavian Anglo-Saxon Bismarckian Southern Eastern p-value a < a p-value of the interaction between each SEP score and welfare state type Guarnizo-Herreno CC, Watt RG. Pikhart H, Sheiham A, Tsakos G. Journal of Epidemiology and Community Health 2013; 67(9):

22 No functional dentition: absolute inequalities by welfare state Socioeconomic position measure Welfare State Type Education Occupational class Subjective social status SII 95% CI SII 95% CI SII 95% CI Scandinavian Anglo-Saxon Bismarckian Southern Eastern p-value a <0.001 a p-value of the interaction between each SEP score and welfare state type. Guarnizo-Herreno CC, Watt RG. Pikhart H, Sheiham A, Tsakos G. Journal of Epidemiology and Community Health 2013; 67(9):

23 Oral health inequalities (education) by welfare state: multilevel approach Guarnizo-Herreño CC, Watt RG, Stafford M, Sheiham A, Tsakos G. Health & Place 2017;46:65-72.

24 Oral health inequalities (occupation) by welfare state: multilevel approach Guarnizo-Herreño CC, Watt RG, Stafford M, Sheiham A, Tsakos G. Health & Place 2017;46:65-72.

25 Inequalities within welfare state regime: Diabetes prevalence by education 15 Low Medium High Age: years England Banks, Marmot M, et al., JAMA, 2006 US Steeper inequalities in USA

26 Relative inequalities in oral health in England and the US Guarnizo-Herreño CC et al. BMJ 2015;351:bmj.h6543

27 Welfare state regimes characteristics change over time effect on health Economic rationalism resulted in widening inequalities in caries severity among 5-year-olds in New Zealand 1 Health in periods of austerity: clear increase in suicides among persons of working age in Greece, coinciding with austerity measures 2 Comparing Greece, Spain, Portugal vs. Iceland: Although recessions pose risks to health, the interaction of fiscal austerity with economic shocks and weak social protection is what ultimately seems to escalate health and social crises in Europe 3 1. Thomson WM, Williams SM, Dennison PJ, Peacock DW. Aust N Z J Public Health 2002; 26: Rachiotis G, Stuckler D, McKee M, Hadjichristodoulou C. BMJ Open. 2015;5(3):e Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S, Stuckler D, Mackenbach JP, McKee M. Lancet. 2013;381(9874):

28 Limitations Interpretation issues Welfare regime approach limitations Variation in social policy areas Change over time Outcomes measurement Different outcomes for different age groups Different outcomes different view of inequalities Nature of outcome (current status vs. accumulation over life course) SEP measurement international comparisons Pathways measurement data quality and relevance Sugar consumption Psychosocial factors Focus more on specific features of welfare provision consider social spending and social rights 1 1. Bergqvist K, Yngwe MA, Lundberg O. BMC Public Health 2013; 13: 1234.

29 Summary main points from the welfare state comparative studies Welfare regimes contribute to explain the variation in oral health among European countries Better population oral health in the Scandinavian regime (more generous and universal welfare provisions), for all SEP groups (including lower) Social gradients in oral health in all welfare regimes, but not systematically smaller in Scandinavian countries Pathways to socioeconomic inequalities in oral health are not universal across welfare regimes, suggesting that their relevance is influenced by the broader political context

30 Policies more likely to be effective in reducing health inequalities Structural changes in the environment (eg installation of smoke alarms, traffic calming measures) Legislative and regulatory controls (eg lower speed limits, vitamin supplementation of foods Fiscal policies (eg increase price of tobacco and alcohol products) Income support (eg tax and benefit system) Reducing price barriers (eg free prescriptions, school meals) Improving accessibility of services (improving transport links, affordable healthy food) Prioritising disadvantaged groups (eg deprived families and communities, unemployed) Offering intensive support (eg systematic, tailored and intensive approaches) Starting young (eg pre and postnatal support, home visiting in infancy, preschool care) Health Inequalities Policy Review, NHS Health Scotland, 2013.

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32 Dental Public Health W: Thank you for your attention MSc Dental Public Health UCL Department of Dental Public Health