You have three main tasks: (1) identify your central claim, (2) develop a working outline for the same proposal p. , and (3) compose a short three pagraph draft section of your white p. 



White Paper Generative Outline

For this exercise, you will compose a generative outline that will help guide your drafting process as you conduct your writing and research over the next three units. You have already made a significant start on your work by completing last unit’s topic proposal. This activity aims to help you maintain that momentum as you begin to compose the first concrete draft of your white paper.

This activity is primarily aimed at developing, or generating, the line of reasoning for your project. You have three main tasks: (1) identify your central claim, (2) develop a working outline for your project, and (3) compose a short draft section of your white paper.

Central Claim

Research-based writing advances a central claim that the writer hopes to persuade her reader of. For the white paper, this central claim is oriented around a problem and a solution. Recall the white papers we analyzed in Unit Four. We might map the central claim of all of “All Health is Connected” as follows:


Significant health disparities for black men exist.


Leveraging prenatal care settings can provide opportunities to redress these disparities.

Central Claim

Since men of color face significant health disparities, healthcare providers should consider how prenatal care settings might be leveraged to improve the health outcomes of black men.

Though breaking down the central claim according to the problem and solution it posits may seem a bit straightforward, doing so reminds us of the sheer breadth of each component.

To persuade her audience, the writer advancing this claim would first need to explain just what health disparities exist for black men. (The writer does indeed take on this task, discussing key health indicators, insurance coverage disparities, and the availability of care – among many other topics). Then, the writer would need to fully describe the solutions she is proposing, along with providing evidence that suggests these solutions would be successful. (The writer takes on this task too, discussing how during the perinatal period, expectant fathers are more mindful of their health, how targeted exercises in self-discovery related to health can benefit individuals, and how insurance processes might be improved – again, among many other things).

The line of reasoning of this twelve-page document then proceeds from the author’s central claim. Identifying your own central will be essential to your drafting process. (You may have already made a solid start in this regard in your topic proposal!) Importantly, this claim might change slightly as you continue your research, draft your document, and receive feedback from your professor and peers. For now, identify the most current version of central claim by completing the table below:



Central Claim

Working Outline

With your central claim identified, you will next draft a concise working outline for your project. Since this is a working outline, you are not expected to identify and list each major idea or piece of supporting evidence that will be in your final draft of this project. Instead, you are expected to provide a map of the current state of your central line of reasoning. Your continued work on your project, along with feedback from your teacher and peers, will allow your line of reasoning to develop in terms of both sophistication and clarity.

Let’s examine “All Health is Connected” once more. In the previous section of this worksheet, we’ve identified the central claim and several core reasons that support this claim. Consider the second and third paragraph of the paper’s introduction:

In relation to the paper’s central claim, we might map the reasoning of these very short paragraphs as follows:

· Central Claim: Since men of color face significant health disparities, healthcare providers should consider how prenatal care settings might be leveraged to improve the health of black men.

· Reason One: Black men experience worse health outcomes.

· Evidence (A) for Reason One: Research shows higher levels of adverse health conditions compared to white men (Source: CDC, 2017)

· Evidence (B) for Reason One: Research shows that these disparities exist between black men and other groups as well (Source: Kaiser Family Foundation, 2007)

There is, of course, much more of the paper’s line of reasoning. (Your instructor may invite you to map other parts of the paper’s line of reasoning during this unit’s class session!) But for now, we can see how the core logic of the white paper derives from its central claim.

For this part of the worksheet, draft a working outline of your white paper in the space below. Remember, your line of reasoning might not yet be fully developed. That’s okay. Write down your central claim, the main reasons you have identified related to it, and the evidence that you’ve discovered that supports these reasons.

You may also consider adding bullets to your outline that say “Need additional reason” or “No evidence for this yet.” Doing so will allow your peers and your teacher to see where you are at in your writing process.

[Insert Working Outline Here]

Draft Section

In the final part of this worksheet, you will now transition from the outlining to drafting. Select a portion of your outline and compose at least three paragraphs related to that portion. Compose those paragraphs in the space below.



Dealing With Inequality in Oral and Dental Health in Developing Countries

Jeanette Jimenez

Institution Affiliation


Professor Turner


Dealing With Inequality in Oral and Dental Health in Developing Countries

The white paper responds to inequality in oral and dental health which the policymakers should consider in both middle- and low-income developing countries. Dental and oral health is becoming a global public health concern because of the severity and distribution of the infection related to dental and oral health. Due to the relationship between the social, environmental, and behavioral factors and the oral and dental health diseases, as well as intensive costs, it appears that the issue of inequality requires more consideration among middle- and low-income developing countries (Bastani et al.,2021). Inequality can either result from inappropriate utilization or access of services or unfair provision of services by the population. In most cases, expenditures worldwide are allocated to dental carriers and their treatment, yet such spending may vary from country to country. In some countries, it might require out-of-pocket payment funding at the moment of clients’ needs which can intensify the access and inequality to dental services. Additionally, dental and oral health is highly dependent on financing. Age, skin color, sex, and gender are among the characteristics that influence the health status of a population and result in the emergence of inequality.

The suggested solutions to the problem in this white paper include the evidence that health social determinants, education, environmental conditions, income, and communities’ life of work, among other factors, just like adequate professionals of oral health play a crucial role in reducing the disparities and reducing the inequality in health. Populations in and with the dentist’s service casts can also determine or affect the affordability and, in turn, increase equity, especially with the low cost of dentists’ services. Insurance coverage for dental and oral health is one of the determinants of the behaviors of the populations to seek health. In this case, the range will increase the access of the services to the people, including the low-income population in the developing countries. The equitable distribution of providers is another proposed solution in that it can result in more extensive geographic access and assist the dental and oral health equity among the population.

The background information that the reader may require in appreciation of the solutions for this problem in the white paper is that the answer should mention that the determinants of inequality may have different weights among the middle- and low-income contexts in the underdeveloping and developed countries. Other information may involve the nature of applicability and generalization of the outcomes.

Ghanbarzadegan, A., Balasubramanian, M., Luzzi, L., Brennan, D., & Bastani, P. (2021). Inequality in dental services: a scoping review on the role of access toward achieving universal health coverage in oral health. BMC Oral Health, 21(1), 1-11.

This article explains how access to health services can be improved more in the achievement of oral health universal health coverage. The paper aimed to determine the accessibility to dental services. The study used scoping review methods, and the initial search involved 4320 articles, from which a sample of 57 articles was obtained and included in the qualitative synthesis (Ghanbarzadegan et al.,2021). The seven main themes indicated in the results obtained from this study include dental services access determinants such as geographical distance, family condition, health demands, socio-environmental factors, cultural factors, services affordability, and services availability. The study revealed that affordability of services, social environment, family condition, availability of services, health demands, geographic factors, and cultural factors could affect the equality and access to dental health.

Further, the results showed the need to consider socio-cultural determinants in applied planning. Addressing the identified factors to improve dental services access can assist in the achievement of universal health coverage in dental and oral health should be considered in policymaking at different levels. This article is relevant to the white paper topic because it aims to explain the accessibility of healthcare services, especially in achieving universal health coverage. Further, it identifies the determinants of oral and dental healthcare access and equity as the cultural factors, affordability of services, family condition, availability of services, health demands, and social aspects.

Bhandari, B., Newton, J. T., & Bernabé, E. (2015). Income inequality and use of dental services in 66 countries. Journal of dental research, 94(8), 1048-1054.

This article discusses the relationship between the use of dental services and income inequality and the role played by the investment in explaining that relationship and healthcare. This article used a sample of 223,299 adults from 66 countries on whom the surveys were administered. The use of dental services was defined as having been treated to solve teeth or mouth problems in the past year, and the Gini coefficient was used to measure income inequality. The results from this article show that the Gini coefficient of a 10% increase resulted in a lowering of 15% the odds of dental services utilization (Bhandari et al.,2015). The results of this article indicate that more equal countries indicate the exact utilization of dental health services. It also supports healthcare investment as the mediator for this investment. This article is relevant to the white paper topic because it provides evidence that investment associated with the high-income generation plays a crucial role in explaining the relationship between income inequality and the use of dental services. The article offers information on the relationship between income inequality and access to dental health services.

Garzón-Orjuela, N., Samacá-Samacá, D. F., Luque Angulo, S. C., Mendes Abdala, C. V., Reveiz, L., & Eslava-Schmalbach, J. (2020). An overview of reviews on strategies to reduce health inequalities. International journal for equity in health, 19(1), 1-11.

According to this article, countries are incentivized to implement and develop health action programs aiming at equity. This study aims to synthesize and identify interventions and strategies that aid health inequality reduction. The study used a systematic strategy search, and a snowball was also utilized. Out of the 4095 articles identified, only ninety-seven pieces were used in synthesizing the evidence. The sampled studies included minority, general, and vulnerable populations (Garzón-Orjuela et al.,2020). The results indicated that the strategies that lead to health inequality reduction are multidisciplinary and intersectoral. This article is relevant to the white paper topic because it identifies the strategies and interventions for reducing healthcare inequality. Further, this study is relevant to the white paper topic in that it considers the minority, vulnerable, and general population in the study.

Reflection on The Current Stage of Work

I feel like the project has identified sufficient evidence to address the inequality in oral and dental health. I am excited about the identified determinants of the disparity, including the social factors, gender, sex, age, family conditions, availability of health services, cultural factors, and environmental factors, and I feel like that is enough if appropriately addressed to solve the issue of inequality in dental and oral health. The elements that I am confused about and require further discussion with the teacher include how sex and culture affect dental and oral health inequality. The question to ask is how will equality be implemented? Who will be the main stakeholders? What will the budget be for implementation?


Bastani, P., Mohammadpour, M., Mehraliain, G., Delavari, S., & Edirippulige, S. (2021). What makes inequality in the area of dental and oral health in developing countries? A scoping review. Cost-Effectiveness and Resource Allocation, 19(1), 1-12.

Bhandari, B., Newton, J. T., & Bernabé, E. (2015). Income inequality and use of dental services in 66 countries. Journal of dental research, 94(8), 1048-1054.

Garzón-Orjuela, N., Samacá-Samacá, D. F., Luque Angulo, S. C., Mendes Abdala, C. V., Reveiz, L., & Eslava-Schmalbach, J. (2020). An overview of reviews on strategies to reduce health inequalities. International journal for equity in health, 19(1), 1-11.

Ghanbarzadegan, A., Balasubramanian, M., Luzzi, L., Brennan, D., & Bastani, P. (2021). Inequality in dental services: a scoping review on the role of access toward achieving universal health coverage in oral health. BMC Oral Health, 21(1), 1-11.


Bastani et al. Cost Eff Resour Alloc (2021) 19:54


What makes inequality in the area of dental and oral health in developing countries? A scoping review Peivand Bastani1*† , Mohammadtaghi Mohammadpour2†, Gholamhossein Mehraliain3, Sajad Delavari1 and Sisira Edirippulige4

Abstract Background: Equity in health is an important consideration for policy makers particularly in low and middle income developing country. The area of oral and dental health is not an exception. This study is conducted to explore the main determinants that make inequality in oral and dental health area in developing countries.

Methods: This was a scoping review applying the framework enhanced by Levac et al. Four databases of Scopus, PubMed, WOS and ProQuest were systematically searched applying to related keywords up to 27.11.2020. There restriction was placed in the English language but not on the study design. All the related studies conducted in the low or middle income developing countries were included. A qualitative thematic analysis was applied for data analy- sis and a thematic map was presented.

Results: Among 436 articles after excluding duplications, 73 articles were included that the number of publications from Brazil was greater than other developing countries (33.33%). Thematic analysis of the evidence has led to 11 determinants that may result in inequality in oral and dental health services in developing countries including per- sonal characteristics, health status, health needs and health behaviours, social, economic, cultural and environmental factors, as well as insurance, policies and practices and provided related factors.

Conclusion: The policymakers in the low and middle income developing countries should be both aware of the role of inequality determinants and also try to shift the resources to the policies and practises that can improve the condi- tion of population access to oral and dental services the same as comprehensive insurance packages, national surveil- lance system and fair distribution of dentistry facilities. It is also important to improve the population’s health literacy and health behaviour through social media and other suitable mechanisms according to the countries’ local contexts.

Keywords: Inequality, Oral health, Dental health, Developing countries

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver (http://creativecom- applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Open Access

Cost Effectiveness and Resource Allocation

*Correspondence: [email protected] †Peivand Bastani and Mohammadtaghi Mohammadpour have equal participations as co-first authors 1 Health Human Resources Research Centre, School of Health Management and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran Full list of author information is available at the end of the article

Background The populations’ oral and dental health is among the public health concerns globally. Evidence shows that the distribution and severity of the diseases related to oral and dental health can vary around the world [1]. While some evidence emphasizes that the prevalence of dental caries is decreased among both developing and devel- oped countries [2], other studies show the high preva- lence of dental diseases among those populations with

Page 2 of 12Bastani et al. Cost Eff Resour Alloc (2021) 19:54

low socioeconomic status [3]. Such these contradictions can simply indicate that the issue of oral and dental health needs to be considered yet.

On the other hand, other evidence, indicates that the treatments applied for oral and dental diseases are con- sidered as the 4th expenditures even among industrial and developed countries [4]. Because of the intensive costs and due to the relationship among the frequency of these diseases and the social, behavioural and envi- ronmental factors [1], it seems that this issue needs more consideration among low and middle income developing countries. In this regard, the previous studies have shown the inequalities in the area of oral and dental health. Such an inequality can be either due to the unfair provision of the services or each of the inappropriate access or utili- zation of the services by the population [5]. According to the evidences almost 4.6% of healthcare expenditures globally is allocated to the dental caries and the related treatments. Such an expenditure is varied from one country to the others and in many regions is funded by out of pocket payments at the time of patients’ needs [6] that can intensify the inequality and access to the dental services.

Equity as one of the main aims for the healthcare poli- cymakers is directly pointed to any potential differences in the population’s health including either their financing, access to the services or the health level of the commu- nity [7]. According to the evidences, different determi- nants can lead to inequality in oral and dental diseases. Among them the social, cultural, ethnical, psychologi- cal and behavioral factors can be considered [8]. In this regard evidence shows that socio-determinants of health (SDH) the same as education, income, environmental condition, the community’s working life as well of the other factors the same as adequate oral health profes- sionals can play an important role in decreasing dispari- ties and as a results, promoting the health equity [9].

At the same time, the present knowledge indicates that the population’s income along with the cost of den- tistry services are among other important determinants that can affect the affordability of the services and con- sequently intensify the inequality [10]. So, a clear iden- tification of these determinants should be mentioned comprehensively to shed the light for policymakers for better allocation of the resources and equitable provision of oral and dental health services particularly in develop- ing countries.

According to what was said, although the indications of inequality in dental services has been reported in many communities, the challenge is much more highlighted among low- and middle-income countries. Accord- ing to the evidences, many inconsistency and knowl- edge gaps are obvious in the area of oral policies among

these countries [11, 12] that make the national, local and regional policy makers pay more attention to this area. In another words, to the best of our knowledge, although many contents are considered a single or mul- tiple cause of inequality in the area of oral and dental health, a scoping review in the context of low and middle income developing countries is not presented. Moreover, as the issue of inequality in health is related to the con- text and setting, the determinant factors may differ from the developed or in transition countries to the developing or under developed ones. Considering all the above, this scoping study is conducted to explore the main determi- nants that make inequality in oral and dental health area among developing countries. This approach can make an opportunity to consider the whole related scope, and explore all the determinants stated in the related litera- ture to pave the way for health policymakers in develop- ing countries in order to plan based on the evidence and applied to the context.

Methods The present scoping review was conducted in Novem- ber 2020. This kind of reviews, is generally applied to define and clarify the determinants and key concepts of a research scope and map the evidences and conceptual boundaries of the topic [13]. Different frameworks are proposed to conduct a scoping review. First of all, was suggested by Arksey and O’Malley with a five obligatory and an optional consequential steps [13]. This framework has renewed by Levac, Colquhoun and O’Brien [14]. According to Levac et  al. all the six steps of the Arksey and O’Malley’s framework was enhanced. In this study the later framework is applied because of more explicit details, clarity and rigor through the review process [15].

Clarifying and linking the purpose and research question At the first step of the scoping review the purpose of the study was confirmed as “determination of the main and sub factor affecting inequality in oral and dental health services among developing countries”. According to this purpose the following research question was defined: “What are the main determinants of inequality in access to oral and dental health services”.

Balancing feasibility with breadth and comprehensiveness of the scoping process At the second step, the area and scope of seeking the evidences were identified. In this regard, four main data- bases including PubMed, ISI Web of Science, Scopus and ProQuest were systematically searched. Related keywords were chosen and they were combined applying logical operators OR/AND in order to increase the sensitivity of

Page 3 of 12Bastani et al. Cost Eff Resour Alloc (2021) 19:54

the search. The main keywords were “dental health”, “oral health”, “socioeconomic”, “healthcare disparities”, “utili- zation” and “inequality”. Although the aim of the scop- ing review was to explore the determinants of inequality in oral and dental health among developing countries, “developing country” was not applied as the main key word because many of the studies directly pointed to the name of the developing country not the general term. The search strategy was conducted up to 27 Nov 2020 considering two limitations for time and language. The time limitation was considered from 1 Jan 2000 to 27 Nov 2020 and the language limitations was defined for those articles which has published in a full text format in Eng- lish. The syntax search is presented in Table  1 according to each of the aforementioned databases. Also, at the end of the process of systematic search, a google search was implemented for retrieving the related pre-prints and unpublished or grey literature in this area.

Using an iterative team approach to selecting studies and extracting data Applying the aforementioned search strategy (Table  1), all the four databases were systematically searched. 6521 cases were reached following this strategy. After reviewing the titles, 4535 cases were remained and after screening and omitting the duplications, a total of 436 articles were included. These articles were screened first by their abstracts and the relevant abstracts were com- pletely reviewed by their full texts. In this step, the eli- gibility of the articles was defined so that, those articles with no English full-texts and those articles with no full- texts format the same as conference proceedings were excluded. Furthermore, those articles in any formats of editorials, commentaries and letters were excluded and were not eligible to analyse because they do not contain

any data-driven results. Another screening stage in this step was selecting those studies according to the list of the developing countries based on the World Economic Situation Prospects released by the United Nations 2020 (https:// www. un. org/ devel opment/ desa/ dpad/ wp- conte nt/ uploa ds/ sites/ 45/ WESP2 020_ Annex. pdf ).

In this regard, all the original or review articles with any qualitative or quantitative design derived from any of the developing countries based on the aforementioned list which indicate the aim of the present scoping review were included. Meanwhile, none of the records identified through other sources were eligible for including data analysis step.

For managing the pre-stated process, Endnote X7.1, by Thomson Reuters was applied. Figure  1 shows the PRISMA flowchart.

Incorporating a numerical summary and qualitative thematic analysis In order to extract the data from the included articles, a data extraction form was prepared including the first authors’ name, the year and place of publication, the study aim and design and the main results (Additional file  1: Table  S1). Microsoft Excel software version 2013 was applied to extract the data. This step is carefully done by one of the researchers (MM) and the extracted results were described according to the frequency of pub- lications via Fig.  2. For evidence synthesis a qualitative thematic analysis was conducted. For this propose, after extracting the effective factors of oral and dental health inequality from each article as the final code, the new concepts were made by categorizing the codes, the topic charting process was applied via a table to determine which codes belonged to each category.

Table 1 The search strategy of the scoping review

Databases Key words combination

PubMed (((“Dental Health Surveys”[Mesh]) OR ( “Oral Health”[Mesh] OR “Dental Health Services”[Mesh] )) AND (((((“Socioeconomic Factors”[Mesh]) OR “Hierarchy, Social”[Mesh]) OR ( “Healthcare Disparities”[Mesh] OR “Health Status Disparities”[Mesh] )) OR “Social Determi- nants of Health”[Mesh]) OR “Social Class”[Mesh])) AND ((((“dental services”[Title/Abstract]) OR (“dental visits”[Title/Abstract])) OR (utilization[Title/Abstract])) OR (“use of services”[Title/Abstract]))

SCOPUS TITLE-ABS-KEY(“oral health”) OR TITLE-ABS-KEY(“Dental Health Surveys”) OR TITLE-ABS-KEY(“Dental Health”) OR TITLE-ABS-KEY(“dental care”) AND TITLE-ABS-KEY(“Socioeconomic Factors”) OR TITLE-ABS-KEY(“Social Hierarchy”) OR TITLE-ABS-KEY(Inequalities) OR TITLE- ABS-KEY(“Social Disparities”) OR TITLE-ABS-KEY(“Social Gradient”) OR TITLE-ABS-KEY(“Health Status”) OR TITLE-ABS-KEY(“socioecon

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