Principles Dental Public Health Oral Health Needs Assessment Jabarifar@dnt.mui.ac.ir دکتر سید...

Principles Dental Public Health

Oral Health Needs Assessment

Jabarifar@dnt.mui.ac.ir

/ 1389 تاریخ : Dr. jabarifar)دکتر سید ابراهیم جباری فر) 2010

دانشیار دانشگاه علوم پزشکی اصفهان بخش دندانپزشکی جامعه نگر

Needs assessment

• As a general rule, establishing the effectiveness of

an intervention must be the most important step.

• Most challenging of all is the task of apportioning

relative priority to different services and recipients.

Cost effectiveness must be taken into consideration

How is dental need usually assessed?

The most commonly used type of need assessment in

oral health care planning is normative or

professionally defined need.

• However, despite its usefulness and extensive use,

normative need is not free from limitations.

Needs assessment

The purpose of needs assessment in health care

IS to assess unmet health and health care needs

in a systematic manner and to gather the

information required to bring about change

beneficial to the health of the population.

Planning health services:

The role of treatment needs assessment

• Conversion of individual items into units of

treatment

Calculation of time and cost required.

Calculation of relative costs to using dental teams

of different types of dental personnel.

Need for health care

Need can be defined as ability to benefit in some way

from health care.

The ability of a population to benefit from health care

depends on two things:

"The number of individuals affected, i.e. the incidence

and prevalence of the condition under question.

" The effectiveness of health services available to deal

with it.

Shortcomings of normative measures

Lack of objectivity and reliability.

Ignores consumer rights.

Lack of consideration of health behaviours and

compliance.

Unrealistic paradoxical approach takes little account of

limited resources.

Bradshaws concepts of need

Normative need: a state of oral health considered as in

need for intervention by a practitioner. A professional

dentist's assessment of need. For example, how many

cavities, need for denture, need for orthodontics?

• Perceived need: an individual's own assessment of

their dental state. Their want for better oral health.

• Expressed need or demand: those perceived needs

that individuals convert into demand by seeking the

assistance of a practitioner.

General ways needs and dental health are assessed

Dental public Health Dental Health

Curative / PreventiveScreeningEducationResourcesExpensive

ExtractionsFillingsScaling

OrthodonticsProsthetics

Normative

PreventiveCurative

UtilisationResources

5 A’s3 C’s

FunctionNormalityNo pain

AestheticsNo 5 D’s

5Ds

Felt

Shortcomings of normative measures Serious

conceptual limitations

"Clinical measures tell us nothing about the

functioning of the oral cavity or the person as a whole"

(Locker 1989).

"Clinical indices are essential for measuring oral

disease; the problem arises when these indices are

used as measures of health and treatment need"

(Sheiham et al. 1982).

Concepts of need

There is frequently a large difference between

normative need and perceived need:

• In dentate older individuals, the treatment need was

85% less when using the socio-dental approach

(perceived needs) as compared with normative

assessment.

• In edentulous subjects estimated treatment need

dropped by about 40% when subjects were assessed

using the socio-dental approach (perceived needs).

A framework of questions to ask when assessing

health needs

What is the size and nature of the problem? What are

the current services?

What do patients want?

What are the most appropriate and effective (clinical

and cost) solutions?

What are the resource implications?

What are the outcomes to evaluate change and the

criteria to audit success?

Need

• Health care needs are those that can benefit from

health care (health education, disease prevention,

diagnosis, treatment, rehabilitation, terminal care).

• Health needs incorporates the wider social and

environmental determinants of health, such as

deprivation, housing, diet, education, employment.

This wider definition allows us to look beyond the

confines of the medical model based on health

services, to the wider influences on health.

Need

• Health needs assessment should not just be a

method of measuring ill health, as this assumes that

something can be done to tackle it.

• Incorporating the concept of a capacity to benefit

introduces the importance of effectiveness of health

interventions, and attempts to make explicit what

benefits are being pursued.

Need

Need in health care is commonly defined as the

capacity to benefit.

• If health needs are to be identified then there

should be an effective intervention available to meet

these needs and improve health.

There will be no benefit from an intervention that is

not effective or there are no resources available to

resource

Need

Assessment of health needs is a systematic method of

identifying unmet health and health care needs of a

population, and making changes to meet these unmet

needs.

• It involves an epidemiological and qualitative approach

to determining priorities, which incorporates clinical and

cost-effectiveness and patients' perspectives. This

approach must balance clinical, ethical, and economic

considerations of need, that is what should be done, what

can be done, and what can be afforded.

Need

For individual practices and health professionals, health

needs assessment provides the opportunity for:

• describing the patterns of disease in the local

population and the differences from district, regional, or

national disease patterns;

• learning more about the needs and priorities of their

patients and the local population;

• highlighting the areas of unmet needs and providing a

clear set of objectives to work towards to meet these

needs;

Need

For individual practices and health professionals, health

needs assessment provides the opportunity for:

• deciding rationally how to use resources to improve

their local population's health in the most effective and

efficient way;

• influencing policy, interagency collaboration, or

research and development priorities; and

• importantly it also provides a method of monitoring

and promoting equity in the provision and use of health

services and addressing health inequalities.

A measure of dental needs should include:

The wants of the individual. Wants are the

individual's perceptions of their own dental care

needs and depend on the oral health status of the

individual, their perceptions of what is normal and

what the possible benefits of treatment are, as well

as on factors such as social class and education.

A prescription of effective and acceptable

treatments or cures and the skills required to carry

out the care (division of labour).

Quality of life: Background

• Today we are working with a concept which

portrays health as a part of everyday living, an

essential dimension of the quality of our lives.

• Quality of life in this context implies the

opportunity to make choices and to gain satisfaction

from living. Health is thus envisaged as a resource

which gives people the ability to manage and even

to change their surroundings.

A measure of dental needs should include:

A clinical dimension based upon sound concepts of

the life history of the diseases.

A measure of impairment which incorporates

functional measures to assess the impacts of the

impairment.

A measure of social dysfunction

Prevalence and incidence

Neither prevalence nor incidence necessarily equate

with need but knowledge of these parameters is

usually an essential starting point for the assessment

of needs.

Prevalence increases if incidence (or the rate of .

relapse) increases.

In health needs assessment it may be important to

estimate both incidence and prevalence.

Quality of life: Background

• The irony is that while so much of the challenge in

health care is social - to enhance the capacity of

individuals to perform desired roles and activities -

the thrust of the health enterprise is substantially

technologic and reductionist, treating complex socio-

medical problems as if they are amenable to simple

technical fixes

Sociodental indicators

• Sociodental indicators is the degree to which

mouth disrupts various aspects of daily life.

• Dental disorders does more than this. How does it

impinge on some aspects such as self-esteem and

embarrassment?

• They provide information on the impact of oral

disorders and the perceived need for dental care.

• They are supplementary to the traditional clinical

health measures.

Quality of life: Denfinitions

• "Quality of life is the degree to which a person

enjoys the important possibilities of life"

(Raphael et al. 1994).

• "Health-Related Quality of Life (HRQoL) is a

multifaceted concept that attempts to

simultaneously assess how long and how well

people live" (Guyatt et al. 1989).

Need

Different domains:

Physical function

Psychological function

Social function

Sociodental indicators Chewing Capacity Index

• Ask them whether can chew 9 indicator foods.

• Eating - avoid prepared foods.

• Sleep and rest - disturbed.

• Communication avoid smiling, difficulty in

speaking.

• Social interaction - embarrassment.

• Avoid social contacts health/appearance.

• Emotion behaviour - worry or concern.

• Work loss.

Need

Different domains:

Impairments- pathology

Disability Disavantage

Handicap Socio psychological

dimensions

What are Oral Health-Related Quality of Life

(OHRQoL) measures?

"Measures that add a dimension of social impact to the

clinical indicators" (Cohen and Jago 1976).

"Measures of the extent to which oral conditions disrupt

normal role functioning" (Nikias et al. 1979).

What are Oral Health-Related Quality of Life

(OHRQoL) measures?

"Measures of the extent that health status and

conditions disrupt normal social-role functioning

and bring about major changes in behaviour, such

as inability to work, attend school, undertake

parental or household duties" (Locker 1989).

Application of HRQoL measures

Measuring the efficiency or effectiveness of

medical interventions .

Assessing the quality of care

Estimating the health needs of a population

Improving clinical decisions

Understanding the causes and consequences of

differences in health .

The justification for the existence of the dental profession in Britain

• Second, loss of efficiency "the individual is hurt by the

toothache he suffers, but the community is equally

harmed by the loss of efficiency in the individual which

toothache can cause".

• Third, pemanent disability "while pain is the most

obvious immediate consequence of dental disease,

disability can also follow if the teeth of the young are

neglected and have to be removed".

Fourth, disfigurement "including the aesthetic and

psychological results of irregular or broken teeth".

What are Oral Health-Related Quality of Life

(OHRQoL) measures?

Subjective indicators that provide information on the

impacts of oral disorders and conditions, and the

perceived need for oral health care.

OHRQoL measures are complementary to clinical

measures.

The justification for the existence of the dental

profession in Britain

In 1956 Lord McNair gave ample evidence that it was the

alleviation of the negative effects of the mouth on daily

performances that justified the existence of dentistry as a

profession:

• First, pain and distress "it is the prevention of this pain

and the distress it causes that the justification for dentistry

in this country is to be found. On this ground alone,

therefore, dentistry stands out as removing one of the

commonest occasions of misery and distress".

How should need be assessed?

"New approaches to patient assessment and

intervention are needed to extend the traditional

model", Mechanic (1995)

How should need be assessed?

Answer: use a sociodental approach. Key factors

in socio-dental approach:

1. Clinical dental measures.

2. Oral Health-Related Quality of Life

indicators.

3. Behavioural propensity.

4. Evidence-based interventions.

OHRQoL measures: use in dental services

Subject centred approach Focuses on health

WHY

Large population surveys (Population profile and needs assessment planing

Evaluation of interventions services (outcomes measures)

WHERE

Needs assessment (OHRQoL measures in combination with clinical measures and behavioural factors but not for progressive life threatening conditions)

HOW

Socio -dental needs

Example: malocclusions

Who has malocclusion? Normative Need (NN)

Who should be treated first? Impact Related Need (IRN)

Which types of treatment should be provided to those in need? (effectiveness + evidence)

Propensity Related Need (PRN)

An Oral Health-Related Quality of Life index for

needs assessment

The child version of the Oral Impacts on Daily

Performances (Child-OIDP) assesses 8 items:

Eating food Speaking clearly Cleaning mouth

Relaxing, including sleeping

Smiling, laughing and showing teeth without

embarrassment Maintain usual emotional state without

being initable Carrying out school work

Enjoying contact with other people

Implications of the socio-dental treatment needs

assessment

It will encourage a shift in emphasis away from the

purely mechanical to the behavioural aspects of

treatment

It will support the development of a health-orientated

model of care in preference to the model that

dominates current dental services.

It will promote the adoption of preventive behaviour

by populations.

An Oral Health-Related Quality of Life index for

needs assessment

The child OIDP includes three levels of

measurement:

• Impairment - oral status and conditions.

• "Intermediate" impacts (pain, discomfort, functional

limitation and dissatisfaction with appearance).

• Ultimate impacts (disability and handicap).

The OIDP and child OIDP focus on ultimate impacts

A socio-dental approach using OHRQoL measures

A key consideration when using OHRQoL measures in

needs assessment is attributing OHRQoL impacts to

specific oral conditions.

How do we know that the impact on eating is caused

by a specific condition (e.g. caries or missing teeth and

lack of contacts) and need type (e.g. restorative or

periodontal unmet need)?

Answer: Using condition··specific scores of the

Condition-Specific OIDP index (CS-OIDP).

Implications of the socio-dental treatment needs

assessment

4. It will guarantee the higher effectiveness of

treatment and a greater degree of long-term success.

5.It will facilitate a better division of fabour in

providing dental care and an improvement in the use

of scarce resources.

The Oral Impacts on Daily Performances (OIDP index)

Both OIDP and Child-OIDP provide a final score that

incorporates the measurements of both frequency and

severity of the oral impacts affecting daily living. They

allow for the calculation of Condition-Specific scores (CS-

OIDP), thus identifying causes of impacts and assisting in

treatment needs assessment by relating particUlar impacts

to a particular dental condition.

OIDP theoretical framework is based on the WHO

framework modified for dentistry by Locker (1989).

Propensity Related Need

Behaviours included in score will differ for each

dental condition. For example:

For dental caries would include tooth brushing

patterns, sugars consumption patterns and fluoride

use.

For periodontal treatment include tooth brushing

patterns and smoking.

Can it work ? Does it work ? Is it worth it?

Efficacy is the extent to which an intervention does

more good than harm under ideal conditions ("Can it

work?")

Effectiveness assesses whether an. intervention does

more good than harm when provided under usual

circumstances of healthcare practice ("Does it work in

practice?")

Efficiency measures the effect of the intervention in

relation to the resources it consumes ("Is it worth it?")

Propensity Related Need

Propensity to health promoting behaviours:

Tooth brushing patterns

Sugars consumption patterns ./ Fluoride use

Dental attendance patterns ./ Smoking

Drinking

Give a score for each behaviour and then add them

up to give overall score.

Effectiveness of interventions

Evidence-based oral health care is at the heart of

the socio-dental approach:

Critical literature appraisal/Systematic reviews:

Cochrane Oral Health Group .

Clinical guidelines

Managerial task: "stop starting non-effective

interventions" and "start stopping non-effective

interventions already used" (Muir Gray 1997).

Health gain" can be achieved by reallocating

resources as a result of identifying:

Non-recipients of beneficial health care intervention

(that is, unmet need);

Recipients of ineffective health care (and releasing the

resources for unmet need);

Recipients of inefficient health care (and releasing

resources for unmet need); and

Recipients of inappropriate health care (for whom the

outcomes could be improved).

EXAMPLE OF USE OF

THE SOCIO DENTAL APPROACH

An Oral Health-Related Quality of Life index for

needs assessment

The type of oral condition determines the choices of

needs assessment pathway:

1. Life-threatening conditions such as orai cancer or

pre-cancerous lesions, fractures or jaw, and severe

infectious.

2. Chronic progressive oral conditions such as active

dentinal caries.

3. Non-progressing such as malocclusion, enamel

deformities, missing teeth, gingivitis.

Objectives

To assess and compare the estimates of

orthodontic treatment needs of grade-6

primary school children using:

• The Normative approach.

• The Socio-dental approach.

Material and Methods

Design: a cross sectional survey

Sample: 1034 grade 6 children (aged 11 to 12 years)

Data collected:

1. Demographic information.

2. Normative need through the Index for Orthodontic

Treatment Need (Brook and Shaw 1989(

Material and Methods

Data collected:

3. Oral Health-Related Quality of Life (OHRQoL)

through the Child-OIDP (Gherunpong et al. 2004)

4. Oral health behaviours (propensity):

- The Simplified-Oral Hygiene Index (Greene and

Vermillion 1964)

- Dental attendance pattern: visit dentist when get

appointment

Implications of using OHRQoL measures for

planning health services

• Encourage a shift in emphasis away from the

purely mechanical to the behavioural aspects of

treatment.

• Support the development of a health-oriented

model of care in preference to the model that

dominates current health services.

• Promote the adoption of preventive behaviour by

populations.

Conclusions

• Estimates of orthodontic need assessed normatively

and socio-dentally differed markedly. The prevalence

of NN and IRN was 35.0 and 10.5% respectively, thus

representing a reduction of approximately 70 per cent

in the volume of treatment need.

• Children with IRN had different levels of propensity

for treatment and required appropriate treatment plans

according to their PRN. Of the 10.5% with IRN, 6.9%

had high or medium-high PRN, while 3.6% were at

medium-Iow and low levels of propensity.

Implications of using OHRQoL measures for

planning health services

• Guarantee the higher effectiveness of treatment

and a greater degree of long-term success.

Facilitate a better division of labour in health

care provision and an improvement in the use of

scarce resources.