A public health approach to public dentistry How the Social Determinants of Health can inform Service Planning and Delivery Shalika Hegde, Lauren Carpenter, Andrea de Silva-Sanigorski, Rhydwyn McGuire, Adina Heilbrunn, Lisa Meyenn, Judy Slape Population Oral Health Research Unit, DHSV Public Health Dentistry Conference, June 2013
Oral Diseases in Australia: An Overview Tooth decay is the most prevalent oral health problem (NACOH, 2004) Five times more prevalent than asthma amongst children (ABS, 2009) >25% of adults have untreated decay (Thomson and Do 2007)
Oral disease in Australia Dental admissions are the highest cause of acute preventable hospital admissions (SCRGSP, 2010) >40,000 Australians hospitalised for preventable dental conditions/year (AIHW, 2010) >26,000 under 15 years (AIHW, 2008) >650 Australian die of oral cancer each year (ABS, 2009)
Oral health care expenditure in Australia Oral diseases are the second-most expensive disease group to treat just below CVD more expensive to treat than all cancers combined Direct annual expenditure on dental treatment during 2008/9: $6.7 billion nationally $1.9 billion in Victoria Sources: AIHW 2007; AIHW 2010
Impact of oral disease Source: Department of Health (1999)
Social Determinants of Health
Adapted from: Fisher-Owens S A et al. 2007 Social Environment Culture Applying these frameworks to oral health Health care system characteristics Dental care system characteristics Family composition Socio-economic status Community- Level Influences Family Level Influences Physical Safety Physical environment Community oral health environment Health behaviours, practices and coping skills of family Social capital Physical Safety Social status Health behaviours & practices Biologic and genetic endowment Child-Level Influences Development Use of dental care Physical & demographic attributes Family function Dental insurance Health status of parents Microflora Oral Health Host and teeth Microflora Substrat e (diet) Host and teeth Substrate (diet)
A Common risk factor approach is beneficial Source: Sheiham and Watt 2000
Oral disease is a key marker of disadvantage Greater levels of oral disease is experienced by: People from low SES Dependent older people Aboriginal and Torres Strait Islanders People residing in rural areas People with disabilities Some migrant groups and people from culturally and linguistically diverse backgrounds (including refugees and asylum seekers)
Health Promotion Ottawa Charter (WHO 1986) the process of enabling individuals and communities to increase control over the determinants of health and thereby improve their health
Effective Health Promotion initiatives Involve populations as a whole in the context of their everyday life, rather than focussing on people at risk for specific diseases Often complemented by targeted activities Directed towards action on the determinants or causes of health and diseases in communities Combines diverse, but complementary methods and approaches Aim for effective and concrete public participation and engagement
The Ottawa Charter and the DoH Intervention Types Ottawa Charter for Health Promotion Develop Personal Skills Strengthen Community Action Reorient Health Services Build Healthy Public Policies Create Supportive Environments DoH intervention Screening & Risk Factor Assessment & Immunisation Health Education & Skills Development Social Marketing & Health Information Community Action Settings & Supportive environments Focus Downstream Individual focus Upstream Population focus
Our current approach to oral disease prevention Compartmentalised approach Mouth separated from the rest of the body Oral Health promotion programs often developed in isolation and not always by those skilled in health promotion practice Doesn t often involve community engagement and participation at all stages of the process Not often informed by public health approaches
Population Profiling of Dental Disease
Profiling the population distribution of dental disease Different from individual risk assessments Community level Solution and equity focussed Population monitoring Evaluation Multi-dimensional Functional needs (vs. normative needs)
Why? We are trying to work out not just what is the size of the problem, but also what it is related to, and identify possible solutions Example What is the balance of influences across the community? for particular population groups? How do they relate to each other? What can be done at a population, regional, community or setting level?
Conceptual framework Determinants Outcomes Policy Funding Services Programs Workforce Eligible populations Fluoride Water System and Services Financing care Delivery models Type of personnel Time invested in prevention and health promotion Socio-cultural SES Education Ethnicity Environmental Location Fluoride Water Health promotion initiatives Use of services Dental attendance Reason for attendance Early detection Care received Referral for care Integration Behaviours Oral hygiene Diet (esp sugar) Alcohol Tobacco Fluoride Disease No. of teeth present Experience of bleeding gums No. of healthy teeth Dental caries experience (DMFT/dmft) Community periodontal index and loss of attachment scores Oral cancer/ mucosal lesions HIV/AIDS-related lesions Tooth wear Dental fluorosis Quality of Life Experience of pain Psychosocial/functional impacts of oral illness Adapted from WHO, Poul-Erik Peterson et al
Socio-Ecological Model of Health WHO Model for Oral Health Disease Surveillance Fisher-Owens Model of Child Oral Health Social Determinants of Health Underpinning theoretical frameworks Profiling Domains
The approach for indicator selection Indicators need to be: Relevant Applicable across population groups Technically sound (valid, reliable, sensitive and robust) Feasible to collect and report Action-oriented Have currency and utility (reviewed periodically)
Example indicators for each domain Domain Element Indicator Policy Local Government Proportion of Local Government Areas with policies addressing oral health risk factors Health system and oral health services Schools & Kindergartens Hospitals Prevention & oral health promotion activities Emergency Care Financing Care Access to services Organisational practices Waiting period Recall period for children Proportion of kindergartens/schools with polices addressing oral health risk factors Proportion of hospitals with policies addressing oral health risk factors Proportion of services preformed which are preventive in public and community clinics Ratio of public emergency oral care to public general oral care Proportion of population eligible for public dental services Distance to closest public clinic from census collection district centroid Proportion of children in the area who access the public system Waiting list time in area Average time taken to recall child patients
Example indicators for each domain Domain Element Indicator Socio-economic status Socio-Economic Status Education Level Socio Economic Index For Areas (SEIFA) Proportion of adults who did not complete secondary school Environmental risk factors Use of oral health services Ethnicity/cultural group Migrants Health care card holders Fluoridated water supply Geographic location General and oral health promotion programs Early Detection /preventive General anaesthetic for children Proportion of adults who do not speak English at home Proportion of children and adults who are migrants Proportion of children and adults who are health card holders Proportion of children and adults without access to fluoridated water Australian Standard Geographic Classification of remoteness Proportion of kindergartens implementing Smiles 4 Miles Proportion of children and adults treated for early oral disease Proportion of children who had an avoidable general anaesthetic for dental care Risk behaviours Alcohol consumption Tobacco use Proportion of adults who drink at levels beyond that which is considered safe in the long term Proportion of adults who currently smoke tobacco
Data Sources
Confirming relationships between variables DMFT with SEIFA ~50% DMFT in non-fluoridated areas DMFT with remoteness
High levels of correlation between individual putative causes Remoteness, smoking, GA, public housing with health care card LOTE, migration, GA, non-early treatment, public housing with distance to public clinic Alcohol, smoking, lower education, lower income with remoteness
Factor Analysis/data reduction Loadings: Factor1 Factor2 Factor3 Factor4 GA rate (Age 0-4) 0.73 0.33 GA rate (Age 5-9) 0.92 GA rate (Age 10-14) 0.87 Distance to public dental clinic 0.84 Remoteness 0.43 0.64-0.36 Non fluoridated town 0.72 % LOTE 0.91 % migrants -0.31 0.88 % eligible population 0.68 % smoking 0.59 Schooling (% not completed year 12) 0.4-0.39 0.74 Income (% with hh income <$400/week) 0.51
Testing use of profiling approach for Variable Description resource allocation Distance Eligible population LOTE NonFluoridated Remoteness SEIFA Standardised distance to the closest clinic Estimate provided by the data analysis group using Centrelink data (HCC holders) Standardisation of the proportion of people who speak a language other than English at home Standardisation of binary variable which is 1 if there is no flouride in the water supply and 0 otherwise. Standardised remoteness : A scale from 1 to 4 which signifies how rural the area is, based on the ABS standard Standardisation of seifa deciles (ABS, previous census)- revised modelling with newly released census data)
Examples of maps produced: Melbourne Sum of the standardised data provided the measure of being at high risk for poor oral health: a higher number = higher need
Victoria
With Medicare local boundaries
A work in progress... Agency population need' rebased need eligible population funding to be allocated (eg $10M) 1 8.02 12.31 3204 $59,689 2 5.76 10.05 6359 $96,744 3 4.56 8.84 13846 $185,334 4 4.51 8.80 3058 $40,722 5 3.71 7.99 16407 $198,521 6 3.60 7.88 53032 $632,835 7 3.57 7.86 1560 $18,554 8 3.13 7.42 13789 $154,909 9 2.93 7.22 916 $10,013 10 2.82 7.11 8838 $95,116 11 2.46 6.75 8835 $90,269 12 2.41 6.70 650 $6,593 : : : : : : : : : :
Implications This approach takes into account the range of influences on community and individual oral and general health status Some of which may appear unrelated to OH Provides a more holistic and multi-dimension view of factors to consider when trying to improve OH Trying to connect people with the right services and strategies, at the right time and delivered in the right way, with the aim to reduce inequity in the burden of disease at a population level
Thankyou!