health - Dental Health Services Victoria

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
Applying these frameworks to oral
health
CommunityPhysical
Level
Safety
Influences Physical environment
Health care system
characteristics
Dental care system
characteristics
Community oral health
environment
Social Environment
Family
composition
Culture
Family Level
Social capital
Health
behaviours,
Influences
practices and coping
skills of family
Socio-economic status
Physical
Safety
Social status
Child-Level
Health
Influences
behaviours
& practices
Family function
Physical &
demographic
attributes
Development
Biologic and
Use of dental care
genetic
endowment
Oral Health
Microflora
Host and
teeth
Adapted from: Fisher-Owens S A et al. 2007
Substrat
e (diet)
Health status
of parents
Dental
insurance
Microflora
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
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
Outcomes
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
Fisher-Owens Model of
Child Oral Health
WHO Model for Oral Health
Disease Surveillance
Social Determinants of
Health
Profiling Domains
Underpinning theoretical
frameworks
Socio-Ecological Model of
Health
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
Schools & Kindergartens
Proportion of kindergartens/schools with polices addressing
oral health risk factors
Hospitals
Proportion of hospitals with policies addressing oral health risk
factors
Health system Prevention & oral health
and oral
promotion activities
health services
Emergency Care
Proportion of services preformed which are preventive in
public and community clinics
Ratio of public emergency oral care to public general oral care
Financing Care
Proportion of population eligible for public dental services
Access to services
Distance to closest public clinic from census collection district
centroid
Organisational practices
Proportion of children in the area who access the public
system
Waiting period
Waiting list time in area
Recall period for children
Average time taken to recall child patients
Example indicators for each domain
Domain
Element
Socio-economic Socio-Economic Status
status
Education Level
Environmental
risk factors
Use of oral
health services
Indicator
Socio Economic Index For Areas (SEIFA)
Proportion of adults who did not complete secondary school
Ethnicity/cultural group
Proportion of adults who do not speak English at home
Migrants
Proportion of children and adults who are migrants
Health care card holders
Proportion of children and adults who are health card holders
Fluoridated water supply
Proportion of children and adults without access to fluoridated water
Geographic location
Australian Standard Geographic Classification of remoteness
General and oral health
promotion programs
Proportion of kindergartens implementing Smiles 4 Miles
Early Detection /preventive
Proportion of children and adults treated for early oral disease
General anaesthetic for
children
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:
GA rate (Age 0-4)
GA rate (Age 5-9)
GA rate (Age 10-14)
Distance to public dental clinic
Remoteness
Non fluoridated town
% LOTE
% migrants
% eligible population
% smoking
Schooling (% not completed year 12)
Income (% with hh income <$400/week)
Factor1 Factor2 Factor3 Factor4
0.73
0.33
0.92
0.87
0.84
0.43
0.64
-0.36
0.72
0.91
-0.31
0.88
0.68
0.59
0.4
-0.39
0.74
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
funding to be
population 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!