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Welcome to Oral Health Matters, a brand new podcast from the Dental Public Health Group at University College London and presented by eminent dental public health expert Professor Richard Watt.
Richard Watt 00:04
Welcome to Oral Health Matters, a podcast that shines a spotlight on oral health and calls for it to be embraced as a key part of the global public health agenda. I'm Richard Watt, Professor of Dental Public Health at University College London. In the second series of our podcast, I'll be in conversation with leading researchers and policymakers from around the world who are working in the fields of global health or public health, and who are interested in issues of equity, community action and the politics of health. In this episode, we're focusing on the topic of equity and how best to move forward with a pro equity agenda in both research and policy development. Addressing health inequalities has been on the policy agenda for many years, but at this challenging time for public health research, it will be interesting to discuss the way ahead. I'm delighted to be joined by two leading lights in this field, Yvonne Kelly, Professor of Lifecourse Epidemiology at University College London, and Co-Director of the new ESRC, funded equalize program focusing on health inequalities research. My second guest is Bulela Vava, founder and president of the Public Oral Health Forum and lecturer in community dentistry at Wits University in South Africa. Both my guests have extensive but very different experience and expertise in health inequalities, research and policy. So thank you both for our conversation today. And I'd like to start our discussion really by thinking for the last 30 years, health inequalities has been investigated by researchers around the world, but in 2026 What do you consider to be the unanswered questions in this field of health inequalities research? Perhaps we could start with you, Yvonne, what are the unanswered questions we currently have in this space?
Yvonne Kelly 02:14
I think, in the context of a lack of consensus about what works, where and how, it's really tricky to have interventions and policies that fit, you know, entire populations. So I think for me, the unanswered questions are around the research needing to have the relevant nuance, and for that nuance to be evidence based, so building consensus and kind of finding mechanisms, identifying the most suitable mechanisms for building that consensus across all of the relevant stakeholders, including, importantly, those decision makers, are really where we need to progress in the research, as well as, you know, twinning that up with action and making a difference in people's lives.
Richard Watt 03:06
Okay, so that's a good start. Bulela in South Africa, in the Global South, what would you say are the unanswered questions in relation to health inequalities research?
Bulela Vava 03:18
As far as what are the unanswered questions, at least in our context, and particularly the South African context, what remains at the forefront for me and for many others is what role do communities play in the pursuit for equity. beyond of course inclusion as voice. But what does inclusion look like when we explore the often uncharted territory when it comes to communities that looks at other aspects, for example, community knowledge systems that ground, of course, the community as an expert, a community as a knowledge holder. But beyond that, I guess, what we often interface with within the global south context is, of course, health systems that have not matured as much, depending on what you call maturity, as much as what we've seen in the Global North. And therefore issues and realities like resource constraints are still something that is pertinent. And therefore we are asking ourselves, how do we design systems that are resilient and sustainable within limited resource settings? And I think much of what we've seen in the direction at least geopolitics is taking us. We are now appreciating, of course, that this is an eminent threat for health systems in the global south indeed.
Richard Watt 04:41
Okay, well, both of you have sort of answered that big question with lots of interesting points, and some of those we'll be able to follow up in a bit more detail in a second. Next question really is that, certainly in the global north, and I suspect this applies also the global South, rather than diminishing health inequalities, rather than than leveling the social gradients in health there's evidence that health inequalities actually could be widening in different areas. Why have we failed, as researchers, to have influence on policymakers to really tackle these unfair, unjust and unacceptable social differences in health. Yvonne, what's your thoughts about the potential failure of us to influence policy makers?
Yvonne Kelly 05:32
Well, starting with a kind of, I guess, the backdrop of the recent, you know, the last couple of decades, so we have, and this isn't about thinking about excuses for those failures, but the context is a global recession and an austerity response, I guess, then followed by a global pandemic, and, of course, the all encompassing consequences of climate change. Within that context, I feel, I think, if we look at the evidence we you know, we've had a wide range of initiatives around reducing health inequalities, and we've seen some small, sort of small or short lived improvements, but then they widen again against this backdrop of austerity, and, you know, political shifts and so on. So for me, I think there are three key reasons why the interventions and the policies have kind of failed to be sustainable. Firstly, they generally don't take a longer view. The centre that we run here at UCL, is a centre for lifecourse research, and really taking in the context or the the lifecourse aspect, I think, is essential when we're thinking about designing interventions and policies to really have that longer term closing the gap in terms of health inequalities. So firstly, we need to take the long view. Of course, we need to look at the upstream influences which are so often lost. You know, many of these kind of interventions with short term gains focus mostly on behaviour change, so really shifting that focus back to the upstream, and we've talked a lot about that over the last 30 years, but I really do feel that is where our attention needs to be. And then, thirdly, that nuance, the necessary nuance, is often lacking. So one size does not fit all. And you know, if we're looking at people with multiple identities facing multiple challenges, the solutions for communities will vary massively. So where I think we have failed is by not being able to take interventions that are suitable for a range of settings and a range of communities. And therefore, you know, we've seen this widening in inequalities. So in terms of the research, I think there's those three different aspects, the lifecourse, the upstream and the nuance, really looking at what we're doing through perhaps an intersectional lens.
Richard Watt 08:06
Thank you again for some really sort of fundamental questions there. And again, moving back to South Africa, have you researchers in the Global South had more success engaging with policymakers? What's your view on that?
Bulela Vava 08:23
As far as our engagement with policymakers within at least the South African context, what still pretty much defines the relationship is a relationship defined by a siloed approach. And what I mean by a siloed approach is researchers are still purely academics who, by and large, still pretty much ignore the very important aspect of needing to understand that research is only translated to the degree to which you as a researcher or the subject of that research interfaces and interacts with the political economy of the day, and in our instance, for example, that remains a significantly large gap. There is research coming out of universities, academic centres, but what we are not picking up is, of course, research that then translates into implementation, and of course, community wide or population wide impact. And the reason for this is also very clear, I think, is that there is no consequence for non-action. And what I mean by that is, when the researcher has met their KRA, or the academic has met their key results areas, there is no incentive for them going over and above and calling for accountability and calling for the translation of very important research, particularly research that has community wide implications. There is no incentive for going further, and therefore a lot of us are quite complicit in finding satisfaction at the desk and of course, feeling that you won, you've saved the world through your publication. And one or two other conference presentations, but a lot more is needed. The research needs to make it into the political realm and in the South African context, often what defines, of course, politics is that you are not dealing with other academics, which has happened, who then, of course, chose politics instead, you are talking to people who don't even understand the language, who also need to be communicated in a way that understands and aligns with their own political agendas and their own political priorities. And that's where, by and large, the problem actually is most, most pervasive, if I can put it that way.
Richard Watt 10:34
So I suppose what we're saying, or what you're both saying, is the political economy of health is fundamental, and I just wonder. Jennie Popay, a professor in the UK, she's coined the expression lifestyle drift. We talk about politics, we talk about upstream, we talk about determinants of health, but when we start implementing often, we drift down to so called lifestyle interventions. Now, Yvonne, you've mentioned that as one of the issues is that happening by accident do you think? Or are there forces or actors that are pushing that agenda? What would your view be on that?
Yvonne Kelly 11:18
Well, it's low cost in terms of the political actors, but it requires a high amount of agency at the individual level, as we know. So, you know, it's like the classic kind of Nike tick, isn't it? You know, you you see, sorry, I probably shouldn't have said a brand, but, you know, we see this, so when we're looking at weight loss programs, for example, we see quite sharp, often, declines in people's weight or levels of adiposity. And then, you know, that's maybe just sustained for a couple of months, three months, maybe, and then we see this huge uptick again, because the interventions require an awful lot of the individual. And then, as you say, lifestyle drift. And then we start to or not we I'm hopefully not complicit in this. But then the, you know, the narrative is around blaming the victim, because you know that they don't have the willpower, etc, etc. So it's very easy, and I guess, lower cost, to have these kind of public education initiatives and so on that advise people around things like diet and physical activity, but then that the they're not sustainable in the longer term, because they actually require intervention at the structural level, you know, to provide safer places for people to exercise, to you know, etc, etc, lower crime neighborhoods and on and on and on. So I do think there is a tension there and a long record in the UK, you know, going back to the Wanless report decades ago, which was all around lifestyle, and that lifestyle drift.
Richard Watt 12:56
Thank you, Yvonne. And thinking again, back down to South Africa, are your policy makers, are your politicians, have they been braver in terms of focusing on on structural determinants, underlying causes of inequities? Do you feel prouder of your politicians than perhaps we are in the in the UK and many other global North countries?
Bulela Vava 13:18
It would be debatable, or rather, let me say that my view is a half and half. On the one hand, I mean, we live at a time where, for the first time, we are seeing a lot more public health related policies come into the fray, particularly around parliamentary debates introducing new legislation that includes, for example, in the area of tobacco control, which, as an organisation, we've also been privileged enough to have an opportunity to make submissions. But it's not only in the realm of tobacco control and wanting to actually come in and regulate heavily a highly volatile industry, particularly where health is concerned, in our context, but what we are now seeing is that we are even tackling the gambling crisis problem which has mental health implications. And what is currently happening is that there's bills currently sitting before Parliament that are also looking at ways at which we can better regulate, and I mean the national treasury at least has published regulations at increasing attacks on gambling, or particularly online gambling products, because we seeing a trend that is now, of course, spilling over into the health realm. So on one hand, one can, of course, then say, well, it seems that our policymakers are paying attention and are doing what is right. But on the one hand, critics can also say, well, they had no choice, because when, when society, of course, when society is impacted. You know, are you looking at the gambling problem, you're looking at tobacco, you're looking at growing inequality within South Africa, which is already known as the country with the world's largest inequality. Everybody knows that it's not in their interest to ignore these ticking time bombs, and as a result, there is a sense of not necessarily self born agency from the politicians, but it is communities standing up for themselves and demanding action for their own benefit.
Richard Watt 15:17
Well, with that, I mean very nice overview, you link very nicely to my sort of next topic really, is this issue of the role of community, of community engagement, community involvement, community control, etc, etc. In terms of researchers, often we tend to exclude the most disadvantage. We tend to exclude groups that are more difficult to reach in different aspects. So I suppose my first question, and again, maybe bulila, you think about this in terms of your research, do you feel you've managed to engage successfully with communities that are marginalized, they're disadvantaged, and if you have tell us some of the ways in which you've achieved that level of engagement,
Bulela Vava 16:04
I think, coming from an oral health background, but at least we've experienced is that it's been very hard because we are launching into a space already at a disadvantage. I mean, oral health has remained a low priority, not only from a policy perspective, but one would argue that while agency sits with communities and individuals affected the system and how it has been designed around oral health, particularly in our setting, has of course, removed a particular, very important lens for communities to have, including ourselves, which is, for example, we only beginning to rise with the sun on the aspect of engaging communities, meaningfully with research, and even there I can't even say we've gotten any successes, because we are still at an infant stage. Because by and large, the system, the design, even the research agendas that have actually fueled our system have largely actually isolated the community as an active participant. Pretty much what still dictates research is that communities are either beneficiaries or participants of some form of a survey or intervention.
Richard Watt 17:12
And Yvonne, moving back to your experience, have you got some examples of meaningful engagement in research that you've worked on, where you feel you successfully did give a voice to the most marginalized and disadvantaged in society.
Yvonne Kelly 17:30
I can think of a number of projects, including those that you and I have both worked on together, Richard, which have been really important work I thin. Maybe I'll talk about what we're currently doing, if that's of interest. So in our Center for Lifecourse, health equity, equalize, we are connecting with various communities and doing that through community stakeholder, organisations, advocacy groups and so on, to set up what we're calling public scrutiny panels. And the program of research has been designed with our community stakeholders from the get go. So we have designed the research questions themselves, and what we do is we take various bits of research to our public scrutiny panels. We ask them what they think, we you know, we get them to sort of input, critique what we're doing, how we're framing things. We also take findings to those groups and then ideas for dissemination. What I think is really important is having those public scrutiny panels as as as we have them currently set up having a really transparent set of processes around engaging with them, including their role in the research itself, and including how we as researchers will make decisions about what to take from our discussions with them and incorporate into the research, because quite often there are very diverging views, and we as researchers then have to have mechanisms and processes about what we take into the research itself, a lot to do with feasibility and the sort of the pragmatic approach in terms of what is actually possible, then having those feedbacks to these groups so that we can, you know, strengthen those relationships and have that high level of trust. Yes, the answer is, yes. I do think we're having meaningful contact with our community groups, but we do have to work hard to, you know, recruit and retain those groups, we don't alienate and participation, all the individuals who are participating in those groups.
Richard Watt 19:49
Great, well maybe, maybe for both of you to think about, we're sort of coming towards the end of our conversation, but thinking how to be as inclusive as possible in our in engagement with communities. And I'm just thinking, Yvonne, you were describing some nice examples there of current work. One of the challenges we often face is when we do engage with communities, the vocal middle classes professionals, they're the ones that jump forward. How can we make it more inclusive, that form of community engagement. I mean, Yvonne, how about both of you give me a view on inclusivity in terms of engagement.
Yvonne Kelly 20:27
I think it's really important to work with those advocacy groups who are working on the ground and understand aspects of people, the realities of people's lives, and working with those advocacy groups to recruit so we don't become overwhelmed by the more privileged members of society. And you know, working with them, identifying suitable participants is really, really key to that inclusive approach, but then also having that resourced properly. So having the staff, research staff, administrative staff, Professional Services staff, to be able to take the time to really nurture those relationships, and, you know, set up those those interactions and that engagement, and then also making it attractive for people to participate, so that people do feel heard and do feel their voices are being included and they are relevant, and they, you know, they do have a voice, literally, but then also underpinning that with perhaps some kind of financial support as well. So for instance, if participants need funds to cover childcare or other forms of care, then doing that and building that into your funding bids or your research bids from the get go. So I think resourcing that is really, really key to that overarching, inclusive approach.
Bulela Vava 21:49
And then just to jump in there, Richard, when I talk about the public Oral Health Forum and the work that we've been trying to do there, I mean, Yvonne made a very important point around advocacy and advocacy, or oral health advocacy, at least in the Global South, at least within the context within which I operate, has not matured to the extent to which we wanted to. And if we are to answer the question of, how do we make more meaningful inclusion for communities within the research space, what I believe is particularly important is again an important call to researchers, to us to actually think about inclusion very differently. Perhaps it is even our framing lens that is wrong, because you often have this assumption that it is us who must make space for the communities at the table as a partner. Perhaps it's the other way around, that actually it is for communities who must open up the table, because I mentioned that there is agency that sits with communities, that sits with individuals, but the question is, how does that agency then translate to action, meaningful participation, of course, in research that communities can identify actually benefits them, prioritizes them beyond just including their voice, but actually prioritizes them as knowledge holders, as solution finders as well. So those are the things that I think become particularly important, that even within the attitude or the frameworks that we use engaging communities, it must be very clear that we take we take this work on as a privilege to work with communities. We take it honestly as a privilege that is worthy of respect and dignity, and that, I believe is actually a good starting point.
Richard Watt 23:28
Well, that's a very nice way perhaps, to end our conversation, because I think this topic of inequalities research, this issue about inclusivity, about meaningful community engagement, and the final discussions we've been having about dignity and respect, resourcing, all these different issues come together as relevant pools to move forward in an effective manner, and perhaps in particular in terms of designing interventions that are sustainable and have a pro equity effect is ultimately our goal. Thanks to our guests, Yvonne Kelly and Bulela Vava, and to you for listening. I hope you found our conversation interesting. You can follow the Dental Public Health Group on LinkedIn, BlueSky and Instagram. Oral Health Matters is produced by the Dental Public Health Group at UCL, with production support from Research Podcasts and funding from the National Institute for Health and Care Research.