University Department of Rural Health
ORAL HEALTH POLICY:
WHAT DOES IT DO FOR
RURAL AND REMOTE
COMMUNITIES?
A/Prof Erica Bell &Dr Len Crocombe
Centre for Research Excellence in
Primary Oral Health Care
University Department of Rural Health
ORAL HEALTH POLICY:
WHAT DOES IT DO FOR
RURAL AND REMOTE
COMMUNITIES?
A/Prof Erica Bell &Dr Len Crocombe
Centre for Research Excellence in
Primary Oral Health Care
University Department of Rural Health
Why oral health matters
Expenditure on dentistry in 2009-10
In Australia was 7.7b (AIHW, 2012).
Those missing out on primary oral
health care:
• frail and older people (Chalmers 2002)
• rural residents (Crocombe et al. 2010)
• Indigenous Australians (Slack-Smith 2011)
• Australians with physical and intellectual disabilities
(Pradhan et al. 2009)
• People of low socio-economic status (Sanders et al.
2006)
University Department of Rural Health
Research evidence of what works and what does not
work in oral health
• Poor hygiene (Davies et al. 2003; Hujoel et al. 2006)
• Poor diet (Rugg-Gunn, 1993)
• Lack of access to primary health care
(National Oral Health Plan 2004-2013)
• Social determinants (Sanders et al. 2006)
• Smoking (Do et al. 2008)
• Low fluoride exposure (ARCPOH, 2006)
University Department of Rural Health
Aims of the oral health policy study
Aim: The ultimate aim of the study
was to contribute to better
understandings about what national
government oral health policy has
been developed and is needed for
rural and disadvantaged
communities
Research questions: 1)‘What kinds
of content define national
government oral health policy in
OECD countries, particularly for rural
and disadvantaged groups?’ and
2) ‘What assumptions underpin the
way national oral health policy
documents describe the policy
problems and solutions for rural oral
health?’
University Department of Rural Health
The sample
Policy document and country
Year
Together for health: a national oral health plan for Wales
[draft consultation document]
2012
Oral health program strategic plan 2011-2014 [USA]
2011
Oral health strategy for Northern Ireland
2007
Good oral health for all, for life: The strategic vision for
oral health in New Zealand
2006
A Canadian oral health strategy
Choosing better oral health: An oral health plan for
England
2005
2005
An action plan for improving oral health and modernising
NHS dental services in Scotland
2005
Healthy mouths, healthy lives: Australia's national oral
health plan 2004-2013
2004
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Analytic procedure
Stage 1. Policy document
content scoping and
quantification.
Stage 2. Discourse analysis
of key assumptions in
policy problems and
solutions for rural oral
health.
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Results
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Results cont’d
• The ‘rural’ concept is relatively infrequent (2%) but often occurs with the
more common workforce concepts
• The language of oral health policy documents is dominated by workforce
and practitioner development concepts
• The 7 concepts for the rural and other disadvantaged groups are not the
least frequent concepts in the study
• The ‘rural’ concept is most present in the Australian and Scotland
documents (7% and 4% likelihood); 1% likelihood in the Canadian policy
and is not found at all in the USA policy document.
• For the concept ‘rural’ the three most frequent paired concepts are:
‘students’ (43%), ‘recruitment’ (36%), ‘Aboriginal’ and ‘Torres Strait
Islander’ (30-29%). All other paired co-occurrences for the ‘rural’ concept
range from 12% to 1%. Generally speaking, the workforce development
concepts tend to be more frequently paired with the ‘rural’ concept than
the wider social determinants of health concepts.
University Department of Rural Health
Critical discourse analysis: key enabling assumptions of
policy stories about rural oral health
In relation to causality, policy documents have three policy
stories…
1.1 The socio economic causality policy story….
• asserts a wide range of socio-economic factors contribute to
unequal oral health outcomes in rural and remote Aboriginal
communities, not clear which ones or how (AUS)
• asserts that the overall poorer health of rural and Aboriginal
communities is linked to poorer oral health, not clear why or
how (AUS)
• asserts lack of access to dental care by vulnerable groups,
particularly rural communities and rural children, is driving
‘inappropriate use of medical services’ (AUS)
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e.g…
“Rates of edentulism (total lack of natural teeth) reflect the
distribution of poor general health in the population. While
about 10 percent of the Australian population is edentulous,
this rises to 16 percent for the Indigenous population, and
to nearly 25 percent for Health Card holders” (AUS)
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1.2 The service model causality policy story
• Asserts private structure of oral health services a major
barrier to preventative care and early treatment (AUS)
• Asserts declining oral health in some vulnerable groups
linked to decline of public infrastructure (NZ, AUS)
• Complexity of mixed public and private service
structures part of the problem of access for
disadvantaged groups (SCOTLAND)
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1.3 The workforce causality policy story
Asserts rural and remote workforce supply challenge is
about culturally conditioned choices made by practitioners
(CANADA)
Asserts even when practitioners/services present there is
unequal service utilisation and this is about the cultural
appropriateness of practitioners and services (CANADA,
AUS)
University Department of Rural Health
In relation to solutions, policy documents
have three policy stories…
2.1 The prevention policy solution story…
Asserts culturally appropriate health promotion and
prevention is important, especially for children (CANADA,
AUS)
Fluoridation seen as a critical strategy for rural oral health
(AUS)
Asserts better access to preventatively focussed dental
care important (AUS)
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2.2 The ‘service model’ policy solution story
Asserts community oral health services can achieve a
‘service hub’ approach to children’s oral health esp. (NZ)
Integrated hubs with regionally-agreed referral and care
pathways are necessary (WALES)
School-based oral health services can help in rural
communities (CANADA)
Aboriginal-controlled oral health services have
demonstrated effectiveness (AUS)
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2.3 The workforce policy solution story
Integration of workforce development approach and
expanded scope of practice important (i.e. encompass a
wide range of oral health professionals and non oral
health professionals for alternative service delivery)
(CANADA, SCOTLAND, AUS)
Incentives can be wide-ranging (financial emphasised but
not sure what ones really work) (CANADA, SCOTLAND)
Range of strategies needed for increasing supply through
training, recruitment and retention, including for public
services (unclear what works) (SCOTLAND, AUS)
Wide-ranging strategies for optimal distribution needed but
unclear which ones really work (AUS)
University Department of Rural Health
Preliminary conclusions
Australia and some other nations have a strong in-principle
policy commitment to rural and Aboriginal and other
disadvantaged groups
But…the absence of policy documents, their dated nature,
as much as their limitations in explaining poor oral health
causes and providing solutions supports the view that oral
health policy has been formed on an ad hoc basis
The next step is to systematically examine the research
evidence for key policy assertions
University Department of Rural Health
Key references
Bell E. Research for Health Policy. Oxford: Oxford
University Press, 2010.
Nutley S, Davies H, Smith P. What Works? Evidence
Based Policy and Practice in Public Services Bristol:
The Policy Press, 2000.
Nutley S, Walter I, Davies H. Using Evidence: How
Research Can Inform Public Services Bristol: The
Policy Press, 2007.
Majone G. Evidence, Argument & Persuasion in the
Policy Process USA: Yale University Press, 1989.
Stone D. Policy Paradox: The Art of Political DecisionMaking. 2nd ed. ed New York: W.W. Norton, 2002.