How the Social Determinants of Health can inform Service Planning and Delivery

A public health approach to public dentistry

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

Community-Level

Influences

Family Level Influences

Child-Level Influences

Oral Health

Social Environment

Dental care system characteristics

Health care system characteristics

Physical Safety

Physical environment

Community oral health environment

Social capital Culture

Family composition

Socio-economic status

Social status

Health status of parents

Physical Safety

Family function

Health behaviours, practices and coping

skills of family

Biologic and genetic

endowment

Physical & demographic

attributes

Health behaviours & practices

Use of dental care

Development

Dental insurance

Microflora

Substrate (diet)

Host and teeth Microflora

Substrate (diet)

Host and teeth

Applying these frameworks to oral health

Adapted from: Fisher-Owens S A et al. 2007

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

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

Behaviours •Oral hygiene •Diet (esp sugar) •Alcohol •Tobacco •Fluoride Environmental

•Location •Fluoride •Water •Health promotion initiatives

Socio-cultural •SES •Education •Ethnicity

Use of services •Dental attendance •Reason for attendance •Early detection •Care received •Referral for care •Integration

Determinants Outcomes

System and Services •Financing care •Delivery models •Type of personnel •Time invested in prevention and health promotion

Policy •Funding •Services •Programs •Workforce •Eligible populations •Fluoride •Water

Adapted from WHO, Poul-Erik Peterson et al

Und

erpi

nnin

g th

eore

tical

fr

amew

orks

Profiling Domains

Socio-Ecological Model of Health

Social Determinants of Health

WHO Model for Oral Health Disease Surveillance

Fisher-Owens Model of Child Oral 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 and oral health services

Prevention & oral health promotion activities

Proportion of services preformed which are preventive in public and community clinics

Emergency Care 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 Indicator Socio-economic status

Socio-Economic Status Socio Economic Index For Areas (SEIFA)

Education Level 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

Environmental risk factors

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

Use of oral health services

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 Proportion of adults who drink at levels beyond that which is considered safe in the long term

Tobacco use 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 resource allocation Variable Description Distance Standardised distance to the closest clinic Eligible population Estimate provided by the data analysis group using

Centrelink data (HCC holders) LOTE Standardisation of the proportion of people who speak

a language other than English at home NonFluoridated Standardisation of binary variable which is 1 if there is

no flouride in the water supply and 0 otherwise. Remoteness Standardised remoteness : A scale from 1 to 4 which

signifies how rural the area is, based on the ABS standard

SEIFA 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!