Background
Methods
Conceptual framework
Study design and setting
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They were classified as Remoteness Area (RA) 2 (Inner Regional Australia), 3 (Outer Regional Australia), 4 (Remote Australia) or 5 (Very Remote Australia) by the Australian Standard Geographical Classification Remoteness Areas (ASGC RAs). The RA categories are defined in terms the physical distance of a location from the nearest access to goods and services based on population size [5].
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Oral health care was a significant problem for the community (as determined by the Chief Dental Officer of each state ie. expert opinion).
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There was no resident dentist/dental surgery, at least one general medical (GP) practice, a health care facility and a pharmacy in the community.
Participants and procedure
Data collection
Data analysis
Results
Characteristics of study sites and participants
Town | Population | Nearest dental surgery | Visiting dental service | ASGC - RA |
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1 | <500 | 248 km | Public dentist: once every 3 months; school dental van: sporadic visits | RA5 |
2 | <1000 | 70 km | No visiting oral health services | RA4 |
3 | <1000 | 40 km | School dental van: sporadic visits | RA3 |
4 | <1000 | 87 km | Private dentist: once a month | RA4 |
5 | <1000 | 179 km | Public dentist: once a year | RA5 |
6 | <1000 | 210 km | Private and public dentist visits: once every 3 months; mobile Aboriginal dental van: once a year; school dental van: sporadic visits | RA5 |
7 | <1000 | 43 km | No visiting oral health services | RA4 |
8 | <1000 | 40 km | No visiting oral health services | RA3 |
9 | <1500 | 214 km | Private dentist: once a month for 3 days; school dental van: sporadic visits | RA4 |
10 | <1500 | 212 km | Public and private dentists: sporadic visits | RA5 |
11 | <1500 | 200 km | Private dentist visits: once a month; school dental van: sporadic visits | RA5 |
12 | <2000 | 62 km | Private dentist visits: once a year | RA3 |
13 | <3000 | 196 km | Public dentist visits: once a month; mobile Aboriginal van: once a year | RA4 |
14 | <1500 | 80 km | Visiting van twice a year; school dental service and public dentist a few weeks a year | RA4 |
Participant Characteristics | Number (n = 105) | Percentage (%) |
---|---|---|
Gender | ||
Female | 74 | 70.5 |
Male | 31 | 29.5 |
Age (years) | ||
≤40 | 55 | 52.4 |
>40 | 50 | 47.6 |
Primary care occupation | ||
Speech therapist | 1 | 1.0 |
Allied Health Worker | 3 | 2.9 |
Aboriginal Health Worker | 3 | 2.9 |
Child Health Nurse/Nurse | 21 | 20.0 |
Director of Nursing (DoN) | 12 | 11.4 |
General Practitioner (GP) | 30 | 28.6 |
Pharmacist | 19 | 18.1 |
Practice manager | 9 | 8.6 |
Receptionist | 7 | 6.7 |
Years in current practice | ||
<1 month | 7 | 6.7 |
1-12 months | 25 | 23.8 |
>1-5 years | 43 | 41.0 |
>5 years | 30 | 28.6 |
Location (State) | ||
Queensland | 57 | 54.3 |
South Australia | 24 | 22.9 |
Tasmania | 24 | 22.9 |
Participant characteristics | Number (n = 12) | Percentage (%) |
---|---|---|
Gender | ||
Female | 5 | 41.7 |
Male | 7 | 58.3 |
Age (years) | ||
≤40 | 2 | 16.7 |
>40 | 10 | 83.3 |
Mean number of years in current practice (range) | 5.2 (0.25-20) | |
Dental occupation | ||
Dentist | 8 | 66.7 |
Dental therapist | 1 | 8.3 |
Dental assistant | 2 | 16.7 |
Practice manager | 1 | 8.3 |
Themes and subthemes
Themes | Subthemes (number of responses) |
---|---|
Access | > Presentations to primary care providers (91) |
> Access for adults (44) | |
> Access for children (24) | |
Barriers to accessing oral health services | > Affordability (38) |
> Travel related issues (42) | |
> Not seen as a priority (31) | |
Managing oral health presentations | > Provision of advice and treatment (91) |
> Confidence in providing oral health advice (88) | |
> Capacity building (73) | |
Communication between primary and dental care providers | > Awareness of dental services (45) |
> Co-ordination (62) | |
> Referral pathways (67) | |
Oral health promotion | > Oral health education (43) |
> Fluoride in water (19) | |
Service delivery models | > Public-private mix model (26) |
> Visiting oral health services (59) |
Access
Rural residents also presented to local hospitals with oral health problems. Hospital staff reported seeing patients with oral health presentations as “very common”, “four in a month” and “six per month”. Rural residents also presented to pharmacies for oral health advice. Pharmacists reported seeing people with oral health problems from “10 per month” to “5-10 per week”. The advice/problems people presented to the pharmacists included:… mostly what we see is dental abscesses, mouth ulcers … and of course extreme pain and tooth abscesses ... (GP8)
Access to adult oral health services (44): Participants from the communities in each of the three States commented on the lack of access to adult oral health services:.General product information, mouth ulcers, oral hygiene products, diagnosis, they have got these sores, trying to work out what they are, how to treat them. (Pharmacist 2)
Having seen patients with oral health problems, nine out of 30 GP participants commented on the poor oral health status of their communities.The obvious one is there is no adult dentist in [name of community 3], so if we are talking about our community that is the main one … (Pharmacist 9)
A number of the rural communities sampled had a relatively high proportion of low-income families and Aboriginal and Torres Strait Islander peoples, factors associated with poorer oral (and general) health. One participant commented:I mean this town has shocking, shocking dental care … (GP 10)
Access to children’s oral health services (24): In one state children’s access to dental care in the three rural communities studied was reported by non-dental health providers to be “very good”. The service provided was “well organised” and included regular visits and interventions provided by a “dental therapist”.Everyone has poor oral health as my demographic are low socioeconomic people and Indigenous. (Allied health care worker 3)
In the communities studied in the other two states, children’s access to dental care services was described as “limited” and “sporadic”.There is a children’s dental service which is very good and my understanding is that most school age children who need dental care get seen pretty quickly, that works quite well. (Pharmacist 10)
Barriers to accessing dental care
For residents without their own means of transportation, who had to rely on others and in some cases health care providers for transport, travel to a regional centre could be more difficult when public transport was not available. In addition, there were also other issues such as childcare, airfares and accommodation that needed to be built into plans when patients had to travel for dental care.… even though there may be a service in [regional town] it might be a low income family, it’s driving there and driving back. It’s expensive to do that. (Nurse 8)
Affordability (38): Affordability of dental services is a barrier that can prevent people from accessing dental care, especially those with limited means or from lower socioeconomic groups.… it is not just the airfares, you have to get accommodation; these are the sort of things that fret a lot of people ... (Allied health care worker 2)
People who were low-income earners but without health care cards, could not access public oral health services and were observed by some health care providers as among some of the most disadvantaged.It costs a ridiculous amount to go to the dentist every 6 months for a check-up and low socio-economic people who don’t have a health care card simply can’t afford to go to the dentist. (Aboriginal Health Care worker 3)
Not seen as a priority (31): Additionally, participants expressed concern that patients would not go to see a dentist for treatment as advised because oral health was, for them, a low priority.Low income earners are the most disadvantaged and highly at risk. The hospital system works really well and with a health care card the treatment is great but if you don’t have that card… (Aboriginal Health Care worker 2)
Delay or failure to obtain follow-up treatment with a dentist meant that a primary care provider could see the same patient a number of times.… but they [patients] don’t go and they make all sorts of excuses and they say I couldn’t make the appointment, I don’t have the money. It is a low priority once the pain is gone ... (GP1)
… the pain goes away and they don’t go to the dentist and then they come back with chronic infection, and I say but I told you to go to the dentist … lots of repeat clients. (GP 7)
Managing oral health presentations
GPs were more likely to prescribe antibiotics and some also reported providing education on oral hygiene and preventive dental care.I administer pain relief, antibiotics and referral on to a dentist or doctor (Director of Nursing 6)
Other primary care providers were more confident in providing oral health advice though less so with assessment or procedural skills.I must admit, I’m not very knowledgeable; I just think, ‘they need painkillers, antibiotics and a dentist’. I certainly don’t really know much else, you know? (GP 12)
Well we are actually not that confident at all. …Nursing we can refer to the doctors but really none of us are really qualified to do more than look and we don’t know really what we are looking for. (Nurse 20)
Capacity building (73)
Given workload pressures and the requirement to be on-call, most GP participants preferred training in oral health to be delivered flexibly, either as online short courses or as short, practical workshops. Doctor and nurse participants recognised the growing importance of oral health education and training for staff working with older persons.I suppose we have to do what is best for our patients and if we can in any way up skill, upgrade our scope of practice in terms of dental care delivery, I’m happy to consider that. (GP8)
Pharmacist participants were interested in oral health training and expressed that training would be best if it were offered online and counted towards their continuing professional development.I think training needs are really important, especially down in aged care, … that oral care is really important, the education of cleaning the dentures, the education of cleaning the patient’s own teeth, the gum protection…(Nurse 5)
I would be very interested in further education in dental emergency stuff like how to put a tooth back in when it has been knocked out. (Pharmacist 19)
Communication between primary and dental care providers
The director of nursing of one community explained that if she was informed about the services she would notify all staff and this would help with the information they provided to patients:I think there is one [dental surgery] in town here, I don’t know anymore, I have not spoken to them, I think there is one dentist here [and] a dental clinic across the road but I don’t know to be honest. (GP12)
The visiting dental service participants also mentioned the lack of awareness primary care providers had about the service they provided to the communities visited.They [visiting dental practitioners] could be here in town and we don’t even know they are here. I could send the information out to all the staff in one email if I had the information given to me. (DON 10)
One dentist suggested a way to improve the situation.In [Name of the rural place] they say “Oh, who are you?” Unless you have been there before and seen the doctors before they have no idea who you are. (Dental Assistant1)
Another suggested that each community should have a contact person for all oral health related issues.The onus would be on the dentist to go around and meet everyone [doctors and pharmacists] and say “look, here are my timetables, this is when I will be visiting”. (Dentist 5)
Co-ordination (62): The majority of the primary care participants expressed the view that they rarely contacted either visiting or regional dental practitioners. Some GPs commented on the minimal co-ordination between doctors and dentists.The community need a contact person for their oral health questions and because I have been around for so long they ring me and trust me to know who to contact. (Dental Therapist1)
This was supported by one dentist who also observed the lack of professional relationships between dental and primary care providers.… to be honest the professional interaction co-ordination between me and most dentists, as a GP and the dentist is nothing. (GP4)
In contrast, the three other dentists interviewed reported that they did communicate with other health care professionals. One stated:We have no professional relationships with the doctors. None what so ever (Dentist6)
An example was given of the co-operation between a visiting dental team and the local primary care providers that resulted in more positive outcomes for Indigenous patients and more effective utilisation of the visiting service.Yes I introduced myself to the pharmacist and I knew the doctors from the hospital. I didn’t actually meet them all in person but just communicated about patients with various diseases. (Dentist4)
Referral pathways (67): Primary care providers commonly referred patients with oral health problems to a dentist. However, many of the primary care provider participants raised the issue of not knowing who to contact when referring patients.In some of our communities, particularly the Indigenous communities we have a lot of “fail to attend”. … so we worked very closely with the DoN. We have seen those numbers drastically decrease by doing that. (Manager of dental service)
There was also a lack of a clear referral pathway between GPs and dentists. GP participants described the communication as ‘one way’. Nursing staff as well as GPs raised the need for feedback from dentists for patients who had been referred to a dentist:Knowing where to refer to … being able to have a name and a number so that if somebody comes in … here you are, you can follow this up yourself or here, I will help you with the phone call. (Allied health care worker4)
… it is fairly difficult to get follow up information, the private ones [dentists] seem to be better, the government service. What’s actually been done? What the follow up is? (DoN 11)
Oral health promotion
Irrespective of professional discipline, all participants emphasised the importance of educating people in the community and children in schools about oral health. The importance of “regular check-ups” and school based oral health promotion was often commented on...... also most families don’t know that they should be actually cleaning the child’s teeth after them till about the age 8 and … half of them might not even have toothbrushes. (Nurse 18)
Fluoride in water (19): Some participants recognised water fluoridation as an important step to improve a community’s oral health. The challenge of providing access to fluoridated water when a community’s primary source of drinking water was from (unflouridated) water in tanks and bottled water was recognized by those working in more remote communities.I really feel that having someone locally doing preventative health advice, especially with the children … I think would make a big difference, just educate them. (GP7)
.... see most of the people here would only drink tank water so what I was actually asking was is our water fluoridated? Maybe that impacts on our teeth being worse? (Nurse 18)
Service delivery models
In order to improve access to oral health services for their communities, some primary care providers suggested having a dentist to treat both public and private patients to make the practice viable.… sometimes they say to me they have been saving money just to go off the island for dental issues because they do not have a health care card … it is frustrating because when there is a government dentist here, they said, sorry, we can’t see this gentleman because he doesn’t qualify for it … (GP2)
This model was referred by the primary care providers as a public-private mix model which would allow a dentist work part-time for the public health service as well as treating patients who were privately insured.We realise that there is probably not enough work for a full time dentist to work only privately or only publicly, but there would be enough between both public and private. (Practice manager 8)
Visiting oral health services (59): When there is no resident dentist, the community has to rely on visiting services. Some primary care providers expressed the view that in these situations, such services should be provided more regularly.I have heard there is a massive surge of dentist numbers and so a compulsory rural rotation through the public system could work. Catch them in their final year and make them aware of rural practice as an option and offer mentors in capital cities (GP 16)
We need a [visiting] dentist more often. (Pharmacist 7)
In one state, the visiting dental service provided oral health services for everyone not just public patients or people with health care cards.We did have the state oral health dental van for children …but having that type of service accessible for the whole community (DoN 4)
This particular service was active in letting local people know that they were coming to the community by contacting the hospital and putting up notices in the pharmacy and the media.They are great. They see everyone, not only cardholders and emergencies also. (Nurse 20)
The primary care providers in this community started seeing the positive impact of having more regular visiting dental services on their community, even when the community was experiencing a decline in population.They put up notices in the pharmacy window and shop windows and advertised in the local paper. … we had a few patients come to the pharmacy and I gave them the 1800 number on the shop window. People are very happy and are starting to rely on the truck. It is free. (Pharmacist 19)
They come in for a couple of weeks twice a year and then they go. So most of the dental needs of the community are being met, especially now that there are fewer people in the local community. (Nurse 21)