Introduction by Croakey: An innovative community health program in Melbourne is delivering culturally appropriate, trauma-informed dental healthcare to residents of public health towers, addressing significant inequity by bringing dental check-ups to their front doors.
This article is published in collaboration with cohealth, a not-for-profit community health organisation, as part of its Health Equity Champion membership of the Croakey Health Media funding consortium.
Marie McInerney writes:
Last year a unique program that emerged from the sudden harsh lockdown of Melbourne’s public housing towers in the early stages of the COVID-19 pandemic conducted a survey in all public housing, community housing, and boarding houses across Victoria.
It asked what services residents wanted to access in the next six months and which ones they were finding hard to get into.
Four-in-ten of the 4,000 residents surveyed named dental care as their most needed, yet least accessible service. Some reported living with pain for years, reluctant to access dental services due to wait times, language barriers, cost, transport issues, low health literacy and poor prior experiences in health care.
“The results were in many cases different according to different areas and housing types, but the need for dental services was uniform, it came from everywhere,” said Gurjot Kaur, who helps lead the Community Connectors program run by community health service cohealth.
Kaur told Croakey that wait times for public dental care in Victoria – now at 16 months according to the Australian Dental Association of Victoria – were a big factor, with residents assuming they had no chance of getting relief or care.
“Even if they had level-10 pain, they would just take a Panadol because they thought there’s no way they could get it fixed,” Kaur said.
“Whether it was a slight problem or a very big problem, they were convinced that care was so out of reach, or that no clinic had time for them.”
Importantly, she said, three-quarters of survey respondents did not know that people living in public housing in Victoria are eligible for priority free dental care.
That lack of knowledge meant that “when they ring to make an appointment through regular channels, they are told there is up to two years wait and they just give up”.
Oral health care at the front door
In response to the survey, cohealth launched a dental van service that is bringing free dental treatment during school holidays to public housing residents aged 18+.
The program is delivered using a Smile Squad van that is part of the Victorian Government’s free school dental program during the school term.
It is led by the Community Connectors, which was among a series of government and healthcare responses to the much-criticised lockdown of public housing in Melbourne. This was found to have violated Victorian human rights laws and highlighted systemic failures and gaps in health and housing services for people living in public housing across Victoria.
The dental service, like the Community Connectors program, is designed to navigate multiple personal and systemic barriers to oral health care for public housing residents.
Like Kaur, all members of the Community Connectors team live or have lived in public housing in Victoria and speak 12 languages between them, including Vietnamese, Arabic, Tigri and Oromo. As well as English, Kaur speaks Hindi, Punjabi and Turkish.
Kaur told Croakey the team was originally worried that residents might not be interested because the dental van service could only offer check-ups and then follow-up referrals to cohealth community dental clinics.
“We thought there would be disappointment about not getting x-rays or treatment on the spot but it turned out that the free check-up was really valuable for everyone who came: it blew me away that they just wanted to know what was happening with their teeth.”
Intessar Ahmed, a refugee from Sudan who is a resident of the Fitzroy high rise public housing tower in Melbourne’s inner-north, welcomed the chance to access the service.
She and her husband have no significant dental issues, but had put off going to a dentist because of the cost.
Ahmed has nothing but praise for the service which, in her case, led to two quick and free follow-up treatments, including fillings.
“I think it is a good idea to give us the opportunity to do this as a community,” she told Croakey.
Other residents needed much more significant and extensive work, including root canal, crowns and extractions, said Kaur. The trust and confidence built with the team for the initial checks resulted in 100 per cent turn-up at priority follow-up appointments at cohealth’s community dental clinics.
One man had not been to a dentist in more than 30 years and told a member of the team he was fearful of doing so, Kaur said.
“So they were really mindful of how to engage with him, they created a really safe space for him,” she said. “Every day he still thanks me, and it’s been more than two months already!”
For another patient, who had a history of trauma and torture experiences in his birth country, the appointment was the first time in nearly seven years he had sought any kind of health support and it has led to a huge change in his life.
“He had struggled even to leave his home,” Kaur said.
“Now he is linked into wider services, and he brings more people in as well because he has spread the word that ‘they’re supporting me with the dental service, with a housing application, with getting in touch with the Community Kitchen’. And now others are dropping in on the team to get the same support.”
Chronic costs
Rising costs of living are currently driving increasing demand at cohealth’s community dental clinics in Melbourne, but lengthy wait lists are far from the only reason why public housing residents may not seek out urgently needed dental care, cohealth said.
For some refugees and asylum seekers, particularly those who have experienced torture or trauma, dental care can be invasive and distressing.
Inability to pay might mean not only being unable to afford to pay a dentist but also the cost of a bus or train or the child care involved to get there. Cost and education are also barriers for preventative care, while families may not have learnt the need for regular brushing or can’t afford to add quality toothbrushes and toothpaste to their shopping trolleys, cohealth said.
The commercial determinants of health also come in to play, with many families having to opt for cheaper unhealthy food and drink rather than fresh fruit and vegetables, and being subject to advertising that convinces them that unhealthy options like juice for babies are good.
Even when people can access treatment, they may end up having to refuse it, including out of shame and embarrassment, she said. For example, some can’t face the 12 weeks they may have to wait after multiple extractions before they can be fitted with dentures.
All of this means considerable pain and discomfort, but the costs go further. Clients with complex medical conditions, for example who require heart surgery or to start medications for cancer or osteoporosis, need to be dentally fit before they can do so.
The Australian Institute of Health and Welfare recently found that oral disorders made up 2.3 percent of total health burden and 4.5 percent of all non-fatal burden in Australia. Long-term effects are associated with serious illnesses like cardiovascular disease, certain types of cancer, pneumonia, dementia and Alzheimer’s disease, and birth complications.
Systemic barriers
Hailing the success of the dental van program, cohealth deputy CEO Chris Turner reflects on inappropriate language used, particularly in the health sector, to talk about communities that are ‘difficult to engage’ or ‘hard to access’.
The reality, he says, is that “the health system itself is difficult to access and difficult to navigate and what that can often lead to is people ending up in the wrong place at the wrong time for the wrong support.”
In the case of dental care, that place for many poorer people is invariably a hospital emergency department, when oral health issues have escalated into crisis.
Reducing the rates of potentially preventable hospitalisations due to dental conditions is one of the key performance indicators of Australia’s National Oral Health Plan 2015–2024. So is reducing inequalities in oral health.
However, while dental disease has reduced across the Australian population in the last 20 years, preventable hospital admissions have not, Turner said.
Factors that correlate with those emergency department presentations included lower education, lower annual income, coming from a rural or remote location, not having dental health insurance, poor access to care, lack of transportation and unemployment, “indicating that the most vulnerable groups are not benefiting from preventative oral health treatments”, he said.
Turner said the program is an example of what can be done with funding that is flexible, unlike much population health funding that is targeted to certain issues, such as vaping or behaviour change around health eating only.
Through that flexibility, the Community Connectors program has been able to “work with everyone in the towers, they weren’t just focused on (one cohort)”, he said.
Victoria’s community health sector – currently expecting significant funding cuts – also provides a unique mix of clinical and social services that make such programs possible and effective, “to both engage your community, to understand their context, and to also bring a clinical response that is not matched across Australia”, Turner said.
“It’s about building that relationship with community and building a sense of credibility.”
• This article is published in collaboration with cohealth as part of their Health Equity Champion membership of the Croakey Health Media funding consortium. cohealth had input into the selection of the topic of the article; Croakey maintained editorial control over the research, writing and publication of the article.
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