1. Beyond Clinical Practice
Population Health©
Reason for being on panel:
To update summit participants on the latest trends in Population Health and to stimulate them to think beyond clinical practice during discussions to follow.
Most dental hygienists work in a clinical setting. They understand that mode of practice very well but feel uncomfortable stepping beyond that. I would like to explore why its important to expand that thinking and some of the challenges involved in doing that.

2. Person
Mouth
Let’s look at a case study. Sharon came to visit her dental hygienist. She had a number of 5 mm pockets and a furcation on her upper 7. The dental hygienist spent over an hour scaling and root planing and very carefully explained to Sharon how to floss and use the rubber tip for her daily home care. The hygienist gave Sharon new oral hygiene tools and sent her on her way - proud of a job well done.
But what happened after Sharon left the office?
As soon as Sharon left the building she lit up a cigarette to calm her nerves after her “torturous ordeal” thinking, “Thank goodness I won’t have to go through that again for another 6 months!”

3. Person
Mouth
Family
She goes home to a baby and 2 preschoolers in a crowded two bedroom basement suite. The youngest is teething, and the other two are fighting because they haven’t been outside all day. The landlord doesn’t like them playing in the yard and the park is too far away for them all to walk to. Welcome home!

4. Community and Friends
Family
Person
After an exhausting day taking care of her family, Sharon’s friends come over with a video and they relax while drinking a case of beer and smoking a few joints. She tumbles into bed after midnight and brushing her teeth is the last thing on her mind. Besides she just had them cleaned by the dental hygienist today!
Mouth

5. Society and Environment
Community and Friends
Family
The next day Sharon goes to work at a donut shop - the money is not great but what can you do with a grade 10 education? Besides that she gets free donuts to take home to the kids.
On the way home she stops off to pick up some groceries. That fresh fruit sure looks good but it’s too expensive. She buys some fruit flavoured drinks and Poptarts instead - they are more in her price range.
When she gets home the kids are tired and cranky. She gives them the fruit drinks and Poptarts for supper as a treat because she feels guilty about leaving them with a sitter all day. That night she quickly brushes her teeth before bed and looks at her new dental tools but is too tired to use them. She’ll start tomorrow night!
Person
Mouth

6. Person
Mouth
Society and Environment
Community and Friends
Family
Provincial, National and Global Forces
If dental hygienists look only at disease etiology and clinical services, they are missing most of the picture.
That night her 18 month old cries most of the night with a tooth ache. His tooth decay may have been prevented if the community had fluoridated water but water fluoridation is a political hot potato in her province. Besides there is only so much money in the health care system and there are other more pressing issues that take priority over Early Childhood Tooth Decay.
The next time the dental hygienist sees Sharon her oral health has deteriorated and her son is on a waitlist for a general anesthetic to fix his rampant tooth decay. The dental hygienist can’t figure out why Sharon doesn’t take better care of herself and her children – after all – she knows what to do – she just has to do it!
Most dental hygienists practice at the bottom 2 levels using a disease-centered, behavioral model known as a “downstream” option (think bottom of pyramid). This model assumes behavior is freely chosen and therefore can be altered - that all the client needs is skills and knowledge to change his behavior to improve his oral health.
Problem:
Requires multiple contacts to be most effective
Is only moderately effective - ineffective and costly in the long run
does not take into account the social and environmental influences on behaviour
Does not prevent those same factors from negatively impacting others

7. What are the implications for the way we practice dental hygiene?
We must look beyond the behavior to the social environment where that behavior is developed and sustained.
The social determinants of health must be taken into consideration when reorienting dental hygiene care.
What is causing the behavior?
Why are they continuing to do it?
What is the “cause of the cause” of disease?

8. Social Determinants of Health
Where we live and work
Support we receive from family and friends
Opportunities for development that we have as very young children
Access to health services
Aspects of our culture that may affect our behaviour
Gender
Social determinants of health include:
Where we live and work
Support we receive from family and friends
Opportunities for development that we have as very young children
Access to health services
Aspects of our culture that may affect our behaviour
Gender
The circumstances in which people live and work have a profound impact on health and well being
social structure and environment not only influence health behavior but also psychological and physiological changes and the disease process over the lifetime
early life experiences effect health in later life
For example a recent study from the University of Washington found that “children of smokers are more likely to use drugs in general and even more likely to smoke cigarettes.” They are also more likely to have child behavior problems like getting into fights and stealing, attention deficit disorder and problems with authority. (J of Abnormal Child Psychology, Aug 2006)
For example: If someone is living on the street it is difficult for them to find facilities where they can wash or brush their teeth or reliable a place where people can contact them. That makes it difficult to find a job. People have been turned down work in the retail or service industry because of the condition of their teeth (ie their smile). If they don’t have jobs they can’t pay for dental care to improve that smile. It’s a vicious circle.
Individuals at the top of the social hierarchy enjoy better health

9. Preventing Oral Disease
Health education
Health Promotion
Population–based prevention
Targeted prevention
Four main approaches to preventing disease that are used in community health.

10. Health Education vs. Health Promotion
Health Education: Increases the oral health knowledge of individuals or groups.
It is not sufficient alone to change behavior.
Downstream approach.
Health Promotion: Supports the individual to turn health knowledge into positive behavior through a variety of strategies (health education being one of them).
Directed at social determinants of health.
Upstream approach.
Examples of Health Education: Presentations by dental hygienists to children in classrooms, parenting groups, chairside instruction
This is what we are mostly taught in our dental hygiene training
One-to-one education is not consistently effective in changing behaviors of parents, decreasing the use of dietary sugars, changing t/b habits (Scottish Intercollegiate Guidelines Network, Prevention and management of dental decay in the re-school child )
Downstream approach
Combined strategies are most effective I.e. the Comprehensive School Health approach uses 3 components besides classroom education – Community Action, health services, school environment
Makes the healthy choice the easier choice.
Utilizes upstream approaches (think top of pyramid)
Health education is one health promotion strategy out of many
Health Promotion Strategies:
skills training,
modifying beliefs about risks
involving the community in planning and implementing,
home-based services,
interdisciplinary approaches,
building on existing resources,
environment or policy change.
Timing is important in order to reach people when they are most ready to change
Use of other disciplines (like street nurses or dieticians) to delivery dental messages
Changing environment – What food is available to children at schools and school events?
Use of people who are established in the community – teachers, caregivers, community care workers
Creating messages and media that are relevant to the community – I.e. a newspaper for street youth, written by other youth in their language and literacy level.

11. Population Health
Aims to make the healthy choice the easy choice!

12. Population Health Looks at health in broad terms (big picture)
Focuses on preventing disease by reducing inequities in health
Benefits all the population and improves the health standards for everyone.
Can take a “common risk factor” approach
Social, economic and public health measures are used to decrease the overall level of risk for the whole population.
Based on the theory that the major determinants of health are social - so the remedies must be as well. This is different from the biomedical (disease centered with clinical treatment) and lifestyle (client responsible to make healthy choices) approaches.
Example: Ban on smoking in public places, water fluoridation
Common risk factor approach – coordinated action by a variety of groups is focused on a set of shared risk conditions and behaviors to address common causes of diseases including oral diseases – I.e. smoking reduction, diet and obesity programs (coordinated action by cancer agencies, dental groups, dieticians…)
Limited and inconsistent evidence that mass media campaigns prevent risk behavior or increase behavior change
Uses ‘upstream’ options to affect health outcomes.

13. Targeted Prevention
Focuses on high risk individuals who have been identified through screening, or higher risk groups, communities or sub-populations identified through epidemiological studies.
Limitations to taking a “high risk” approach:
Better risk assessment tools are needed
Must have services in place to be able to treat after identifying
Is palliative in nature and doesn’t change the underlying causes so there is a never-ending need
Most individuals do not continue to seek dental care after initial treatment
Example screening in schools and referral for treatment
Example: Providing fluoridated tooth paste to “high risk” children every few months has been successful in Scotland. (SIGN, Scottish Intercollegiate Guidelines Network, Prevention and management of dental decay in the pre-school child. Nov. 2005)

14. Consideration for Targeted Approaches:
In the general population a small group has the highest needs.
The largest group has moderate needs.
Where should resources be focused?
On the high need group where a few people will benefit?
On the moderate need group where the majority of the population will benefit but the needs of the high risk may not be met?
It can be very expensive focusing resources on the high risk groups – and it impacts the fewest people.
A combination of both population-based and high-risk approaches is now being recommended.

15. Bottom of the pyramid are “downstream” options (where most dental hygiene care now happens).
Top of the pyramid are “upstream” options (where most of the influence on health inequalities occurs).
For example the same time and energy spent on one client in a dental office could influence 100 – 150 times more people if it was used to train teachers to give dental info to their students.
Dental hygienists need to shift to more upstream activities if they want to increase their impact on the oral health of the population.
Activities higher up the pyramid have a greater impact on health inequities in relation to the time and energy spent.

16. Upstream/downstream options for preventing oral disease:
Adapted from: From victim blaming to upstream action: tackling the social determinants of oral health inequalities. R.G. Watt, Community Dent Oral Epidemiology 2007; 35: 1-11.
Traditionally most dental hygienists have focused on the bottom 3 arrows.
May need to look to other disciplines to see examples of how they use upstream options (I.e. nursing and nutrition).
Examples of upstream;
Teaching oral care to students in caregiver training programs.
Collaborating with nutritionists to develop food sales guidelines for BC schools.
Consultants for the development of the Model Core Program Paper for Dental Public Health
Department Manager for a Health Authority (hospital and public health programs).
Tobacco Reduction Manager.
Coordinating oral health programs for first nations’ communities.
Oral Health Manager at the Ministry of Health
Providing input into a survey of competencies needed to work in public health
Lobbying for funding low cost clinics, improved dental insurance coverage for low income earners

17. Challenges: Financial:
Shifting the mindset from “fee for service” to salaried.
More training is needed on accessing funding (such as writing grant proposals).
Public health and community agencies can not offer private practice salary compensation.
Most population health activities are not in the fee guide. In Sweden where the focus is on reducing health inequities, most dental professionals work in public health programs and private practices are the exception.
DH are not used to accessing the variety of funding in the public sector and therefore may have difficulty funding projects.
Dental hygienists are very highly paid relative to their training and skills beyond clinical practice. It may be difficult for agencies to justify paying a diploma level hygienist $40-$50/ hour when their other professionals (with degrees and master degrees) who deal with life and death situations make < $35/hour.

18. Challenges Education:
Are diploma level DHs prepared for community practice?
Where do DHs get the training needed to do advanced community practice work?
Business skills - Human resource management
Fundraising - Community development
Epidemiology - Program planning
Research
Should community practice be designated a “specialty”?
We need to look at:
If sufficient time is given to community health education at the diploma level,
Whether the information taught is up-to-date
Whether students get sufficient opportunity to develop community practice skills as well as clinical practice.
Many community practice DHs have gone elsewhere for their post diploma level education because the Dental Science degree did not meet their needs. The Canadian Public Health Agency is reviewing competencies required to work in public health including dental public health. We may need to take look at dental hygiene education to see if it meets those competencies.

19. Challenges: Creating competent community health dental hygienists:
Can private practice DHs make the shift to community practice?
Can DHs work as part of a interdisciplinary team?
Can they also work autonomously?
Do we have DHs ready to replace an aging workforce?
Is this work only for public health hygienists or do clinical hygienists have a role?
Many dental hygienists working in public health programs in BC will be retiring in the next 7 years. Do we have dental hygienists ready to take their places?

20. What still needs to be done?
Improved training opportunities for DHs interested in working in community settings.
Opportunities for dental hygienists to learn and work collaboratively with other professions.
Better skills to research, analyze epidemiological data, evaluate and publish our work confidently.
High quality intervention studies.
Greater leadership and lobbying from provincial and national DH bodies around oral health issues.

21. Population Health is not just for public health!
How can all dental hygienists make the healthy choice the easy choice in their communities? Ie
Developing food sales policies through your child’s PAC,
donating toothbrushes and toothpaste to food banks,
media campaigns,
setting up a community fund for oral care for low income adults…
Supporting low cost clinics in your area
Volunteering for a community agency like the cancer clinic, AIDS group, crystal meth program