Oral health disparity between Indigenous and Non-Indigenous Australians

Studies have shown a great health disparity between Indigenous people and their non-indigenous counterparts; the life expectancy for Indigenous people is 10-11 years less than non-Indigenous people (Health Info Net [HIN], 2012). A major contributing factor to this is poor oral health as oral diseases not only affect the mouth but have been associated with cardiovascular diseases (Ylöstalo, et al., 2006), diabetes, stroke and premature/ low birth weight babies (HIN, 2012). This problem is exacerbated with a lack of education on oral hygiene, transport and a lack of quality health services in rural areas. These barriers restrict Wuchopperen, a local Cairns health service, from providing effective services. This raises the issue of health inequity and the need to fund practical, culturally appropriate and sustainable preventive programs to address this health issue (ibid).

Periodontal diseases, including gingivitis (inflamed gums) and periodontitis (destruction of tooth supporting tissues), are more common among Indigenous children and adults than among their non-Indigenous counterparts and this is evident in QLD where Aboriginal children were observed to have a three-fold higher caries (tooth decay, cavities) experience than non-Indigenous (RRH, 2012: NCBI, 2006: AIHW, 2007). Due to lack of dental care and education on such issues, oral health problems can manifest into more serious issues such as oral cancer and endentulism (complete tooth loss) (HIN, 2011). This is a problem in Cairns, with over 54% of Indigenous adults reporting having, or previously had chronic symptoms of gingivitis and a further 36% going without treatment and reaching the point of periodontitis (NSAOH, 2004-06). Another study found only around one-fifth of Indigenous children and less than 5% of children under five brushed their teeth regularly (AIHW, 2012; Brazen & Kruger, 2007). This is possibly a result of the 24% that admitted to never personally educating or encouraging their children to practice oral health (ibid). Oxfam suggests that “the appalling state of Indigenous health today is a result of decades of neglect and inadequate services” (Oxfam, 2013). While this may be the case, no single factor can be identified as the reason for this. Instead, it is a complex interaction of factors such as: cultural perceptions of oral health; lack of access to quality health services; inadequate education; remote location; inadequate housing and living conditions; no access to fluoride; exposure to a Westernised diet; and health foods not easily available in remote areas (Gracey, 2000; RRH, 2012; AIHW, 2004-06). Slee & West (2013) agree with this by stating “Australians in remote areas have decreased access to dental care because of a lack of staff, limited facilities and large distances to care.”

Indigenous Australians' use of toothbrushes and fluoridated toothpaste is not at recommended levels and this can be accounted for as oral self-care may not have been required with a traditional diet, so these practices did not form part of many Indigenous cultures and is not adequately taught in community schools (Harford & Spencer, 2003: DHA, 2005; Bio Med, 2007). A study in NT in 2003 found low levels of regular preventive oral health care among remote Indigenous children as it noted 84% of the children in the study used a toothbrush, but only 20% used toothpaste on a daily basis and the use of toothpaste generally started relatively later in life (around 4 years old) when personal skills are taught in school (Bio Med, 2007). In addition to this, Indigenous communities are often excluded in dental van visits, such as Yarrabah and the Cape region and this strongly disadvantages communities as they miss out on critical dental check-ups (RRH, 2012; UB, 2012). Less than 5% of those younger than five years of age brushed their teeth regularly and this illustrates the need for an improvement (ARCPOH, 2007).

With Indigenous people comprising half (49%) of the population of ‘very remote’ areas (Australian Institute of Family Studies [AIFS], 2011), it doesn’t come as a surprise that 78% of Indigenous Australian over 15 and 95% of children suffer from poor oral health and remain untreated (Health Bulletin, 2013). Professional dental care within remote communities is significantly lacking and as a result is a primary barrier to preventing sufficient change for the oral health disparity (RRHA, 2013; Harford & Spencer, 2003). This means that a large proportion of Indigenous people would generally need to travel long distances to see a dentist, sometimes over poor roads with vehicles in poor condition, however may not have access to either public or private transportation (Bio Med, 2008; NCBI, 2006). Wuchopperen worker, Daniel Noble, reveals that staff did travel to run community health programs however lack of government funding has virtually shut down this service (Noble, 2009). Health worker J Cartwright explains that, “The Federal Government has the same powers to fund oral health services as it does for other medical services; however oral services receive relatively little state or federal funding.” (Cartwright, 2010). This illustrates the need for more dental workers in remote areas and government or state funding to support oral health services.

Further research showed that even the Indigenous populations living in an urban setting are not receiving adequate and culturally appropriate dental care. The Australian Dental Association (ADA) explains that it isn’t the result of a lack of services as the local indigenous health service, Wuchopperen, has two fully equipped dental rooms at its Cairns clinic and a dental van prepared to travel to Atherton and outlying communities (ibid). Currently, there is only a single local dentist who sees patients one day a week at Wuchopperen (Filling the Gap, 2013). “In the Indigenous communities around Cairns and the Atherton there is a dental blackhole. The waiting list for basic care is one year and that is causing people with minor problems to develop acute or chronic conditions.” (ADA, 2003) Dr Roller, a Wuchopperen volunteer, explains that “there was a long waiting list … minor dental issues can increase in severity while people wait for volunteers” (Roller, 2006). While Wuchopperen staff comprises of 80% Aboriginal or Torres Strait Islanders (Noble, 2009), in remote areas there is not a range of services to choose from, especially Indigenous focused care. This becomes a large problem as there are currently few Indigenous people working in oral health services as dentists, dental therapists, or other oral health professionals (HIN, 2012; Filling the Gap, 2013). It is likely that Indigenous people may feel more comfortable visiting an Indigenous dentist than a non-Indigenous dentist for reasons such as language and Indigenous patients often prefer to visit with family members and friends which is not normally accommodated (DHA, 2005; Brighter Futures, 2008; HIN, 2011). This appalling state of oral health in far north Queensland signifies the need for more oral health workers focused on indigenous care.

Based on this evidence there is a clear need for a culturally appropriate service that is available to those in rural and remote areas. One aspect of the problem is transport and this can be improved by the mobile dental service (or dental van) that Wuchopperen has available. At the moment it only makes annual visits to a small number of schools (Filling the Gap, 2013). Expanding this service to a wider range of schools and adding another mobile service to attend those in need in rural and remote areas (such as the Cape region), increases the amount of people visiting professional health services and may in turn improve dental health outcomes. According to Barbara Moore, University of Buffalo (UB) Mobile Dental Unit director, a dental van provides access to a dental provider without having to worry about transportation or proximity to a dental office (UB, 2011). Moore has been running a mobile dental service to children in remote areas since 1997 and based on her 16 years of work experiences she proves a dental van treats 1700 children a year who wouldn’t normally see a dentist, resulting in fewer procedures and treatments like fillings and extractions (ibid). A dental can would be effective, as studies found 65% of primary school children would much rather visit a school dental van as it has more of a “comfortable and child friendly appeal” (Medical Teams, 2013; DHHS, 2008). A dental van was set to be launched for use in Thursday Island in December 2013, however with a “lack of staff and funding pressures” the van is sitting idle with no health workers to operate the truck (Courier Mail, 2013). Queensland Health Minister Lawrence Springborg claims it is another case of the Federal Government paying a one-off cost (dental van) without any ongoing funding to cover day-to-day operational costs (ibid). Wuchopperen worker Toni Raiwaquavuka recognises this problem as she states “funding is continually shut down on key programs before they see an end result” (Raiwaquavuka, 2011). The answer to this common problem would be a long term funding program specifically focused on oral health care in rural and remote communities. President of the ADA agrees with this by concluding that governments must “fund fully equipped, skilled, trained and experienced mobile dental teams to ensure access to comprehensive dental treatment for Aboriginal and Torres Strait Islander communities.” (Bite Magazine, 2013). Also, hiring a full time dentist to work 5 days a week would increase the amount of potential patients treated tremendously. Currently there is only one dentist visiting Wuchopperen’s clinic one day a week, which is clearly not enough. A full time dentist would also allow the dental van to make more trips to communities in need. To further prevent transport being an issue, it is recommended that Wuchopperen add another shuttle bus and extend their service to further outlying communities and the greater Cairns region. This will allow more Indigenous people to utilize Wuchopperen’s dental service effectively and overcome the barrier of transport and living rural and remote.

In addition to expanding services available to Indigenous communities a holistic educational approach is needed. Indigenous leader, Yvonne Butler affirms, “Education is the greatest single weapon to overcome disadvantage and the impact of this health gap affects me and other Indigenous people to this day” (Butler, 2007). With the help of Wuchopperen, an integrated oral health program, aimed specifically at Indigenous people, is recommended to be implemented into primary and secondary school curriculum. Professor Hong found in a study that “In order for health education projects among vulnerable groups to be effective, they need to be designed with a deep understanding of the target audience.” (Hong, 2002). This illustrates the need for Indigenous teachers and dental professionals that work in the communities as they have a strong understanding to the culture. A study in the Northern Territory found that 96% of students would feel disinclined to attend school if their teacher was non-Indigenous (NTNS, 2009; May, 1999). Toni Raiwaquavuka, a Wuchopperen worker agrees with this by stating that “more educational programs aimed at promoting healthy living” and “more Indigenous health workers” can help improve health issues facing Indigenous people in Cairns (Raiwaquavuka, 2009).

The oral health education sessions should include instructions on proper dental hygiene techniques which will be provided by Wuchopperen to better enable the services through development of personal skills (Wuchopperen, 2013). The sessions will include the fundamental technique of impact learning where graphic images of oral cancers and severe dental issues will be displayed in hopes of preventing the students from becoming one of the 36% of Indigenous people suffering from chronic periodontal disease and remaining untreated (NSAOH, 2006; ARCPOH, 2007). This is beneficial as, “The technique of impact learning has been proven successful through the use of startling or disturbing images and statistics as students are highly impacted by what they have seen or heard” (Faculty Focus, 2012). Dr George Johnson justifies this by saying “impact and repetition learning can have a strong impact on a student and often sway their attitudes and behaviours” (Johnson, 2008). A program in Queensland (Healthy Weight Program) with an aim for healthy lifestyles and weight management focused their education on community based workshops and tutorials and has been proven a success for educational programs (HIN, 2011). The program provided ongoing training and learning material and left long lasting lifestyle changes among the community (Get Healthy, 2013). Combined with this will be annual visits to key problem communities such as Yarrabah and Thursday Island for a dental check-up and refresh the students on correct procedures. This repetition on personal hygiene is a key learning technique as Will Turner iterates “It is through repetition we learn important and long lasting lessons in life; repetition is by far the best way to learn, representing 96% of all learning.” (Turner, 2011).

Overall, the current state of Indigenous oral health is more than three times worse than its non-indigenous counterpart (HIN, 2011). Due to lack of funding and a number of barriers such as lack of accessible dental services and education, Wuchopperen fails to effectively address this appalling health issue. In attempt to overcome these barriers recommendations have been suggested. These include better utilising the mobile dental service at Wuchopperen, making dental care more accessible to those in remote communities and educating the Indigenous population on correct oral health hygiene procedures. These justified recommendations address the barriers currently preventing improvement to the health issue and following these suggestions, the Indigenous population will be on the path to diminishing the poor oral health issue.

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