As a registered dental hygienist, much of my focus within the course MHST601 has surrounded access to oral health care within Canada. As part of each unit I have explored populations that struggle to obtain access, the social determinants that can impact their lack of access, the limited funding that does exist, and the future of bridging these barriers to care. There are many groups within Canada that struggle to access care. However, I chose a few groups to focus my understanding and research during this course:
• Children
• Indigenous populations
• Low income/homelessness
In many ways oral health can be thought of and defined the same as overall health. Throughout the course we explored several different definitions of health. The World Health Organization defines health as “a state of complete physical, mental, and social well-being” (World Health Organization, 2020). However, this definition excludes individuals with any form/degree of disease or disability and labels them as definitively ill. This definition defines someone with any form of dental disease as chronically unhealthy. One other definition I explored and believe better represents all Canadians health was created by Norman Sartorious, a German-Croatian psychiatrist. Sartorious discussed 3 definitions/paradigms of health (Sartorious, 2009).
1. Health is the absence of any disease or impairment.
2. Health is a state that allows an individual to adequately cope with all demands of daily life.
3. Health is a state of balance and equilibrium that an individual has established within themselves and their social/physical environment.
The advantage of these definitions is that disease does not replace an individual's health. It may affect their ‘balance’, but not eliminate their level of health. With this definition, those with a disease or disability remain aware of the need to work simultaneously on two tasks. One to remove or alleviate the disease, and two to establish a state of balance between oneself, and their relationship with their environment (Sartorious, 2009). This can be made true for oral health. If an individual has poor dental health, they can work to achieve a balance between their oral condition, and their environment.
An individual's level of health is highly influenced by the social determinants of health. The social determinants of health are the broad range of conditions in which people are born, grow, live, work, and age. These determinants can be significantly shaped by the distribution of money, resources, and power (Centre for Disease Control & Prevention, 2019). Regardless of which end of the spectrum an individual falls within the determinants, it affects their level of health. Many of the determinants are intertwined with one another, which can perpetuate an individual remaining within a certain level.
Access to dental care is often inaccessible due to many social determinants of health, which I discuss in detail in a previous blog post. Some of what I believe to be the most influential factors affecting an individuals access to dental care are:
• Income and social status - Dental care is costly, if an individual does not have expendable income they may not receive important care.
• Employment and working conditions - Dental insurance (or lack of) through work can heavily influence access to care.
• Childhood experiences - poor childhood experiences, due to poor oral care, can create a lifelong aversion/non-emphasis on oral health.
• Physical environments - Many Canadians reside in rural areas, which decreases care options & accessibility.
• Healthy behaviours - non-healthy foods/drinks, smoking, and inadequate homecare results in poor oral health.
Throughout the course I chose to discuss three populations that lack adequate access to care. In separate blog posts I discussed Early Childhood Caries (ECC), Indigenous populations, as well as low-income/homeless populations.
Early childhood caries is the most common childhood disease throughout the world, and within Canada, it accounts for 30% of all day surgeries in pediatric hospitals. It is a complex, multi-factorial, and largely preventable chronic disease that is influenced by biomedical factors, and the social determinants of health (Canadian dental association 2014). The negative effects of ECC can lead to lifelong impacts on quality of life. I discuss ECC in more detail within a previous blog post.
Throughout Canada all public program funding accounts for less than 6% of all dental expenditure, with indigenous care being just a fraction of this small percentage (Lange, 2019). Indigenous dental care is funded by the Non-Insured Health Benefits Program (NIHB). The NIHB states that it aims to provide care for more than 850,000 indigenous people with coverage for a range of medically necessary health benefits when not otherwise covered (Government of Canada 2020). While this program sounds like a great solution to accessing care, it has immense setbacks and room for improvement. The services are extremely limited, and often offer only partial coverage to its users, and require immense hurdles to obtain coverage. I discuss the difficulties with care(for both users, as well as dental providers), cases where the program has created an extreme lack of care, as well as a summary of coverage in a blog post.
(Lange, 2019)
In a previous blog post I have also discussed how homelessness has a large impact on oral health, as it has an impact on virtually every social determinant of health. Within Canada on any given night there are at least 235,000 individuals homeless (Rech, 2019). Dental issues such as missing/decayed teeth, oral pain, gum disease, and related conditions are common in those who are homeless (Guirguis, McNeil & Hwang, 2014). Accessing basic healthcare is often a struggle for those who are homeless. They utilize the emergency department up to 5 times more often than the general population, often obtaining primary healthcare in emerging (Hwang, 2001). When accessing basic healthcare is s struggle, it is even more difficult to access (mainly private) dental care. Often oral health is understandably not a priority for those who are homeless as there are many other competing factors such as obtaining food, shelter, money, etc.
In Unit 4 we explored several multi-level models of health, in a blog post I further understand ECC by using the social-ecological model of health. In the discussion posts another classmate (Draya) explored a less traditional model of health called the 5 whys analysis. I believe that this is a simple method to get to the root cause (or causes) behind an issue. It helps visualize why an issue has occured. There is never a quick fix, and always more behind a situation.
(Expert Program Management, N.D.)
An example of this:
Sadie (a 6 year old) presents in the dental office for her first ever appointment - an emergency walk in appointment.
Why? She has several decayed and abscessed teeth that are causing her pain.
Why? She and her caregivers have not looked after her teeth and she consumes a very sugary diet.
Why? She hasn’t been to the dentist before, so her & her caregiver have not been educated on good oral hygiene practices.
Why? Her mother has 3 children younger than Sadie and was working 2 part time jobs
Why? Her partner left her, she is looking after 4 children on her own.
Initially looking at this situation a dental professional could say why hasn’t her mother brought her in for regular visits, this is neglectful. When in reality the mother is stretched extremely thin being a single mother looking after 4 children trying to keep a roof over their heads and food on the table, dental care had become less of a priority. If Sadie and her family lived in an area where dental care was publicly funded Sadie could have received the dental care and treatment required to prevent her teeth from becoming decayed & abscessed. By using this 5 whys analysis we can see that this may not be an individual issue, it is instead a policy and funding issue.
How do we increase accessibility to these, as well as other vulnerable populations within Canada? One of the first steps it to acknowledge how crucial oral healthcare is. It is important to understand its important place within systemic health. The bidirectional relationship between oral and systemic health is becoming better understood, but there is much more to be understood (Canadian Centre for Policy Alternatives, 2011). Once this link is established and better understood I believe and hope more emphasis will be placed on preventative dental care. This will begin to play a larger role within our publicly funded healthcare. There are of course some publicly funded programs and coverage now. However, there are many shortcomings and gaps within these programs. With time and importance, these programs will expand and better serve all Canadians, resulting in increased oral health and ultimately systemic health.
References
Canadian Centre For Policy Alternatives. (2011). Putting Our Money Where Our mouth is: The Future of Dental Care in Canada. https://www.caphd.ca/sites/default/files/Putting%20our%20money%20where%20our%20mouth%20is.pdf
Canadian Dental Association (2014). CDA Essentials: The Canadian Dental Association Magazine. 1(4). https://www.cda-adc.ca/en/services/essentials/2014/issue4/files/assets/common/downloads/publication.pdf
Center for disease Control and Prevention. (December 19th 2019) Frequently asked questions: Health Equity. https://www.cdc.gov/nchhstp/socialdeterminants/faq.html
Expert Program Management. (N.D.) The 5 Whys. https://expertprogrammanagement.com/2019/05/the-5-whys/
Government of Canada (2020). Dental benefits guide: Non-insured health benefits program. https://www.sac-isc.gc.ca/eng/1579538771806/1579538804799
Guirguis-Younger, M., McNeil, R., Hwang, S., (2014) Homelessness & health. University of Ottawa Press. https://ruor.uottawa.ca/bitstream/10393/30952/1/9780776621487.pdf
Hwang, S., (January 2001). Homelessness and Health. Canadian Medical Association Journal. https://www.cmaj.ca/content/cmaj/164/2/229.full.pdf
Lange, T. (2019). Polishing-up for the Election: Lessons from Indigenous Dental Care. YYC policy. https://www.yycpolicy.org/blog/2019/10/10/polishing-up-for-the-election-lessons-from-indigenous-dental-care
Rech, N., (April 2019). Homelessness in Canada. The Canadian Encyclopedia. https://www.thecanadianencyclopedia.ca/en/article/homelessness-in-canada
Sartorius, N,. (2006). The meaning of Health and its Promotion. Croatia Med Journal, 47 :662-664. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080455/pdf/CroatMedJ_47_0662.pdf
World Health Organization. (2020) Constitution of the World Health Organization. https://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf?ua=1).
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