How are oral health services for Aboriginal people in rural and remote Australia helping to close the gap in life expectancy?
On 19 November 2014, a number of clinicians, policy makers, community members, academics and consumers joined the Key Thinkers Forum in Sydney to discuss how oral health services for Aboriginal people in rural and remote Australia are helping to close the gap in life expectancy and achieve health equality.
The guest speakers were: Dr Kerry Chant, Chief Health Officer, NSW Ministry of Health; Mr Boe Rambaldine, Statewide Manager, Aboriginal Oral Health, NSW Ministry of Health; Ms Debbie McCowen, CEO Armajun Aboriginal Health Service; and Ms Kylie Gwynne, Director, Poche Centre for Indigenous Health, University of Sydney.
This was the fourth Poche Key Thinkers Forums to be held. As with previous forums, a briefing paper was sent out to everyone involved in advance of the forum. The paper can be found at www.sydney.edu.au/poche
Comprehensive notes were taken at the event in order to develop this ‘Poche Opinion’ on the topic.
Aboriginal and Torres Strait Islander oral health in context
When it comes to oral health, ten years on from having a national plan focused on the improvement and expansion of services, the current statistics on Aboriginal and Torres Strait Islander health demonstrate that significant problems remain.
According to the Draft National Oral Health Plan 2015-2024:
- Aboriginal and Torres Strait Islander people on average experience poor oral health earlier in their life and in greater severity than the rest of the population.
- Many Aboriginal children experience a high level of dental decay. The NSW Child Dental Health Survey 2007 found that levels of untreated dental decay were more than twice as high among the Aboriginal child population compared with the non-Aboriginal.
- Aboriginal adults attending public dental services experience tooth decay at up to three times the rate of their non-Aboriginal counterparts and are more than twice as likely to have advanced periodontal (gum) disease;
- Aboriginal people experience complete tooth loss at almost five times the rate of the non-Aboriginal population;
- Aboriginal people are twice as likely to experience toothache and to avoid certain foods due to oral health problems;
- The rate of potentially preventable dental hospitalisations for Aboriginal and Torres Strait Islander peoples is higher than other Australians.
- Aboriginal and Torres Strait Islander people have higher rates of poor oral health, and experience higher rates of chronic diseases than the rest of the population.
With over 43% of Aboriginal and Torres Strait Islanders living in inner or outer regional Australia and 21% living in remote areas, accessibility of services is a key factor contributing to the current gap between the oral health of Aboriginal and Torres Strait Islander peoples and the rest of the population.
In addition to geographic barriers and lack of transport options, cost can often be a barrier, as can cultural differences between patients and the oral health workforce. Many Aboriginal and Torres Strait Islander adults avoid dental care due to cost and there is limited representation of Aboriginal and Torres Strait Islander peoples in the oral health workforce. Many dental services are not culturally sensitive.
Due to the impacts of poor general health on oral health and vice versa it as most important to target the common risk factors in preventive strategies.
Suggestions outlined in the draft National Oral Health plan include:
- Increasing community engagement in the planning and delivery of holistic health services that include oral health;
- Promoting the inclusion of cultural competency in training, education and assessment, clinical management protocols and guidelines;
- Developing integrated models of care that incorporate oral health education, prevention and screening in primary care services;
- Increasing the representation and engagement of Aboriginal and Torres Strait Islander people in the oral health workforce;
- Possibly expanding existing primary health practice incentives for oral health services for Aboriginal and Torres Strait Islander people
This plan is important because it will bring focus and structure to Aboriginal oral health services, funding and priorities.
With the new National Partnership Agreement (NPA) for adult public dental services starting on 1 July 2015, the states are due to begin discussions with the federal government for a significant increase in funding. The earlier this can be guaranteed the better, as existing services would be able to be ramped up and existing staff retained. It is well known that job security leads to less attrition, increased productivity and better client services.
Acknowledging that there is work underway by government health authorities to address the problems surrounding oral health in rural and remote communities, the discussions on the day largely revolved around the practical avenues to prevention, partnerships and working strategically.
The guiding principal underlining the discussions was that oral health is everybody’s business and therefore every individual and every organisation involved in Aboriginal communities can play a role in improving the current state of affairs. Recognising this was seen as key to achieving a truly integrated/holistic approach to oral health that can be felt broadly across the country.
Given what is known about the poor state of oral health in many rural and remote communities and the many and varied reasons behind this, it is clear that focussing efforts on helping to prevent oral health disease is imperative. It is pleasing to see that incorporating oral health education, prevention and screening in primary care services is one of the key suggestions in the Draft National Oral Health Plan for 2015-2024.
A return to providing dental screening in school was raised as one possible solution, which may work more effectively than purely promoting good oral health practices, which may or may not have a lasting effect or may fall down in the implementation due to the social and economic barriers faced by many children and adults in remote Aboriginal communities. To date, screening in schools has been proven most effective in regional areas with smaller schools and where there is enough staff to cater for follow-up demands.
Incorporating oral health education and promotion into home visiting programs was also suggested as a prime opportunity to educate new parents and pre-school children about the benefits of good oral hygiene and a healthy diet, as was developing educational messages tailored for short and long day care centres.
Throughout the discussions about prevention, it was reiterated that in order for any strategy to be effective in the long-term the Aboriginal community itself had to be genuinely engaged in the planning and delivery of these holistic health services. This includes Aboriginal health workers and community leaders. It was noted that to help facilitate this, the curriculum for nurses may need to be revisited to ensure it incorporates adequate training in the area of oral health and provides a deeper understanding of the various interlinked issues to be overcome in rural and remote communities.
Other ideas to be explored included:
- communicating with general health workers on what their role entails/what the expectations are;
- upskilling dental assistants, encouraging further training – potentially an untapped resource;
- providing mixed models of training, including group training – an effective model in Aboriginal communities
- becoming more innovative with web based training tools;
- giving incentive to private dentists who address prevention as well as treatment;
- embedding prevention into accreditation and thereby encouraging changes in the curriculum
- harnessing the power of social media to engage with the community on oral health;
- implementing programs like the market basket review to compare the costs and availability of healthy food in communities, shopping and cooking groups;
- promoting the traditional Aboriginal diet – using this a source of pride;
While various ideas for augmenting existing prevention strategies have been put forward, it is clear that a strategic approach is needed. In practical terms this needs to begin with an understanding that oral health is part of health and is therefore oral health promotion is the responsibility of all health professionals.
Encouraging mainstream health services to embrace oral health as part of their work is a key part of the change process.
When it comes to the delivery side, experience has shown that the most efficient and effective programs are those developed from a scalable model that leverages off existing services, systems, resources and infrastructure.
In addition to witnessing what can be achieved by working within the existing health system, Poche and the communities they have worked with have seen where strategic partnering can lead. The Poche model is a testament to what can be achieved when ideas are put into practice and resources are pooled for collective impact.
The partnership with Armajun Aboriginal Health Service and Pius X Aboriginal Health Service brought together the knowledge and resources of Armajun Aboriginal Health Service, Pius X, the Poche Centre for Indigenous Health, the Centre for Oral Health Strategy (COHS), Hunter New England Health District and local dentists.
This partnership has delivered significant service delivery across eight communities, and screening and referral across a further 11. In addition to helping Aboriginal people access quality oral health care and learn how to protect themselves against easily preventable oral health diseases, the point of the Poche model is to demonstrate what can be done so that others can replicate the success. Importantly, this model is the subject of a collaborative research project which is providing qualitative and quantitative evidence about the efficacy of the approach including: community need; community satisfaction; occasions of service; clinical governance; and so forth.
In closing, good policy exists nationally around Aboriginal oral health. The challenge will continue to be in the translation of policy to service delivery. It appears that where there are planned, integrated and regular oral health services in the community there are positive impacts with respect to treatment of acute oral problems. There are significant issues, however, in embedding prevention and early intervention, and reducing the incidence of caries, particularly in children. There is also a great need to restore oral function and dignity for the many Aboriginal people in rural Australia with few or no teeth.
Funding of oral health is uneven and insufficient at both the state and commonwealth level.
Aboriginal people deserve access to high quality oral health services that meet their current needs and help prevent future oral disease. The impact and efficacy of oral health services must be measured and service providers must be accountable for the quality and cost of their service.
Some service providers have trouble attracting high quality oral health providers and universities have an important role in ensuring graduates have excellent clinical skills as well as demonstrated cultural competence. Public oral health services often have good intent, and strong policy and funding incentives to treat Aboriginal patients but lack the capacity to effectively build trust and engage Aboriginal patients in their service.
These matters require development if we are to genuinely close the gap in oral health for Aboriginal people in Australia.