Embed Size (px)
Citation preview
Principles Dental Public Health
Oral Health Needs Assessment
/ 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.
