Targeting Upstream Social Determinants of Health

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  1. Goal
  2. Background
  3. Gaps and Opportunities
  4. Specific Areas Of Interest
  5. References

September 2020

Oral Health Disparities and Inequities Research Program
Center for Clinical Research
Division of Extramural Research

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Goal

The goal of this initiative is to support research on how to optimally address upstream social determinants of health that can often present a barrier to optimal oral health and impede the effectiveness of preventive research interventions, particularly in vulnerable and underserved communities. To achieve this goal, this initiative will encourage multi-disciplinary collaborations, mechanistic research, multi-level research, and the use of complex systems science approaches. The overarching goal of this research initiative is to generate scientific evidence to help inform policies and practices to reduce and eliminate oral health disparities.

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Background

Despite remarkable improvements in the oral health status of the general population in the United States over time, health disparities continue to persist in certain groups, including racial/ethnic minorities, individuals of lower socioeconomic status, rural and urban dwellers, sexual and gender minorities, and at the intersectionality of these and other vulnerable and underserved populations who continue to experience a higher burden of most oral diseases across the lifespan than their counterparts.1 Early interventional approaches to address these disparities focused primarily on modifying individual behaviors, and were proven to be largely unsuccessful in improving oral health outcomes.2

To better understand the complex interplay of factors or determinants that can influence disparities and potentially provide targets for interventions, the National Institute on Minority Health and Health Disparities has developed a research framework to model the multiple levels and domains by which these factors can influence health outcomes.3 A similar framework has been proposed to understand how the vast array of individual, community, and population-level factors can interact to influence oral health disparities.4

The set of factors that impact health beyond individual-level characteristics are often referred to as “upstream factors” or more commonly, social determinants of health. Social determinants of health (SDOH) are sometimes loosely defined as the conditions in the places where people live, learn, work, and play that can affect a wide range of health risks and outcomes.5 Some examples include: access to healthy foods, access to quality health care, reliable transportation, stable housing, and economic stability. Societal or macro-level influences, including structural racism, discrimination, and certain policies can result in inequities observed in these determinants.3,6

There has been an increased recognition of the important role that SDOH play in influencing health, particularly among vulnerable and underserved populations, and the need for novel research frameworks to address them.7-9 While the concept of multi-level research is not new to oral health disparities research, there is a paucity of research on understanding the specific mechanisms by which SDOH influence oral health outcomes or the complex interplay between different SDOH. Emerging research methodologies, such as those utilizing systems science approaches, hold great potential in helping to elucidate complex interrelationships between SDOH and oral health, and inform interventions to reduce and eliminate disparities.10,11

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Gaps and Opportunities

This initiative provides an opportunity to build upon research NIDCR is currently funding through the established Oral Health Disparities in Children Consortium (RFA-DE-15-006, RFA-DE-15-007), where studies are using multi-level research approaches in clinical trials aiming to reduce health disparities. The central focus of this initiative would be to develop a deeper evidence-base on the complex mechanisms by which SDOH influence oral health outcomes and how to best intervene on them, as part of comprehensive oral health promotion and disease prevention. Specifically, the following knowledge gaps could be answered through this initiative:

  • How can systems science approaches be utilized to better understand the complex interrelationships between SDOH and oral health outcomes to identify targets for interventions?
  • What are the causal pathways and mechanisms by which SDOH contribute to oral disease?
  • How can oral health promotion and disease prevention interventions be tailored to address SDOH as part of comprehensive interventions?

This initiative is timely in that it addresses a 2019 National Academies’ report recommendation that calls for advancing research on addressing SDOH in healthcare settings.7

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Specific Areas Of Interest

Examples of research that would fall within the scope of this initiative could include, but would not limited to:

  • Utilizing systems science approaches (including simulation modeling and use of Big Data) to understand the complex interplay between SDOH and oral health disparities, and identify targets for interventions;
  • Elucidating the mechanisms and mediators by which upstream SDOH shape pathways that lead to oral disease (e.g. dental caries, periodontal disease, or oral cavity and oropharyngeal cancer) and oral health disparities, to identify targets for intervention;
  • Conducting multi-level interventions that directly address upstream SDOH (e.g. cariogenic diet, access-to-care, or transportation barriers) as part of the overall intervention to improve oral health;
  • Demonstrating the use of social workers, case managers, or community health workers to promote oral health and address SDOH barriers; and
  • Demonstrating the feasibility of delivering interventions to improve oral health in non-healthcare settings (e.g. barbershops, places of worship, or community venues) that may mitigate structural SDOH barriers.
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References

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Last Reviewed
July 2024