1. 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

2. University Department of Rural Health A/Prof Erica Bell &Dr Len Crocombe Centre for Research Excellence in Primary Oral Health Care ORAL HEALTH POLICY: WHAT DOES IT DO FOR RURAL AND REMOTE COMMUNITIES ?

3. 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)

4. 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)

5. 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?’

6. University Department of Rural Health The sample Policy document and countryYear 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 strategy2005 Choosing better oral health: An oral health plan for England 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

7. University Department of Rural Health 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.

8. University Department of Rural Health Results

9. University Department of Rural Health 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.

10. 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)

11. University Department of Rural Health 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)

12. University Department of Rural Health 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)

13. University Department of Rural Health 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)

14. 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)

15. University Department of Rural Health 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)

16. University Department of Rural Health 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)

17. 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

18. 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 Decision- Making. 2nd ed. ed New York: W.W. Norton, 2002.