ARPA: Dentistry, deprivation and poverty

New research into the nature and causes of social disadvantage in Australia has highlighted how restricted access to dental treatment is contributing to deprivation, social exclusion and poverty. Although there is a lot of information about the distribution of income and other economic resources, far less is known about the subjective experience of social disadvantage, and the project is attempting to fill this gap.

The research is developing new indicators of disadvantage that are grounded in the experiences and insights of those faced with the realities of poverty. This has involved talking to those who confront different forms of disadvantage and building research instruments and indicators that reflect the lessons learnt from those conversations. A series of focus groups was conducted with users of welfare services, aimed at getting them to talk about their problems and aspirations so that the research could reflect first-hand the experience of poverty (Saunders & Sutherland, 2006).

Participants identified the barriers that prevent them (and their children) from participating socially and economically. Lack of resources was a key theme, although participants focused on the inability to buy specific things like decent housing and affordable health care that are needed to achieve a decent standard of living. Many participants reported that the high costs of prescriptions and medications were a significant problem, whilst others found that the high cost of specialist health care services had caused them to miss out on needed assistance.

Another theme that emerged as a major cause of deprivation and social exclusion was the absence of an affordable public dental scheme for low-income and disadvantaged people. There was particularly strong agreement about the inadequacy of access to dental treatment and its high cost. Many reported that they had had to forego major dental work because they could not afford it, while others waited for years to access affordable dental treatment. As one person observed: ‘I’m on the waiting list so I’ll probably be that old when I get my teeth done I won’t have any left’. And there was a strong awareness of the flow-on effects of having bad teeth, with one person noting that: ‘Health impacts on employment … people will have bad dental health, often their teeth are in such a state they won’t access training, they won’t access employment so it has this roll-on effect to all the other areas of their life’. One participant’s description of Australia’s public dental system as being ‘like that in a third world country’ vividly captures the extent of a problem that brings shame to such an affluent country.

The focus group findings were incorporated into a survey questionnaire that was designed to establish if the concerns expressed in the focus groups existed more widely. It also aims to build a national picture of material deprivation and social exclusion by establishing who is missing out, and in which areas.

Two linked surveys were conducted. The main survey was sent in the middle of 2006 to 6,000 members of the population drawn at random from the federal electoral roll. Just over 2,700 responses were received, a response rate of 47 per cent, which is well above average for social surveys of this type. At the same time, a shorter version of the survey was completed by just under 700 clients of some of the welfare services operated by the research collaborators. The latter survey provides a unique insight into the views and living conditions of this disadvantaged group, and allows their circumstances to be compared with those of the general population, based on responses to the main survey.

Respondents to both surveys were asked which things (from a list of 61 items) they thought no one should have to go without. The list included basic items (a substantial meal at least once a day, warm clothes and bedding and prescribed medications), access to key services (health care, disability and mental health services), items that affect people’s sense of identity and capacity (to be treated with respect by others, and good budgeting and English-language skills), forms of participation (in social events, community activities and the labour market), and consumer durables (a car, a mobile phone, a washing machine and a DVD player). Also included were two items specifically about dental care: access to dental treatment, when needed, and an annual dental check-up for children.

Having asked which of the list of items were essential the survey also asked the respondents whether or not they had each item on the list and, if they did not, whether or not this was because they could not afford it. These questions allow us to identify who is deprived, in the sense of facing ‘an enforced lack of socially perceived necessities’ (Mack & Lansley, 1985, p. 39).

Of the 61 items included in the main survey, 48 were seen as essential by a majority of respondents and 30 received at least 90 per cent support for being essential. Dental treatment if needed ranked seventh overall, with 98.6 per cent regarding it as essential, while an annual dental check-up for children ranked 18th with 94.7 per cent support. The views of the welfare service clients on the two dental items were very similar, with 96.6 per cent and 95.0 per cent support, respectively.

Significantly, the level of community support for dental treatment being essential has been stable over time. A previous survey, conducted by the author in 1999, asked the same question and found that 98 per cent thought then that dental treatment when needed is essential—virtually identical to the 98.6 per cent support identified in 2006.

Inadequate coverage of existing dental services was highlighted by the survey’s findings about who does not have access to the two forms of dental care, and how many are denied access because they cannot afford it. The main findings are summarised in Table 1.

Almost one-fifth of those in the main sample (which is broadly representative of the general population) do not have access to dental treatment when needed and close to one-third do not have an annual check-up for children. (The latter figure would be even higher if expressed as a percentage of only those who have children.) Both rates are far higher among the welfare service clients sample, where both are well in excess of 50 per cent. These results are of deep concern, particularly since the surveys were conducted after a period of sustained economic growth had delivered rising real incomes to most people. Clearly, this increased prosperity did not extend to making dental treatment any more affordable.

The final two columns of Table 1 show the extent of dental care deprivation, defined as those who do not have access to dental treatment because they cannot afford it. Around one in seven in the general population are deprived of dental treatment and almost one in ten have children who are deprived from having a dental check-up. (Note that those who do not have children will not indicate that their lack of an annual check-up is because they cannot afford it, and will thus not be included in the deprivation figures).

Dental care deprivation rates of those in the sample of welfare service clients are an indictment of the existing provisions—not in terms of their quality, but in terms of their access and affordability. Almost half (46 per cent) are deprived of dental treatment and over one-third (35 per cent) cannot afford to get an annual dental check-up for their children. These figures thus confirm the views expressed in the focus groups, and point to the importance of this issue in adding to the many other problems faced by the most disadvantaged in the community.

It would be unthinkable if the government were to decide that Medicare will no longer cover the treatment of accidents and illnesses associated with (say) people’s hands. There would be a huge public outcry on the grounds of common sense, compassion and equity, and the perpetrators would be banished to the opposition benches for decades, perhaps permanently. The mere mention of such a proposal highlights its absurdity and lack of political credence.

Yet this is exactly what we have done by not providing an adequate and affordable public dental scheme. In the process we have made what should be a relatively minor irritant (a toothache) into a major catastrophe for many people, not just those who are already doing it tough. The consequences of the lack of coverage and affordability of dental care and treatment in Australia is a source of deprivation that makes life even harder for those in poverty, reduces their self-esteem and employment prospects, preventing their inclusion, economically and socially. This situation requires urgent action.

REFERENCES

Saunders P. & Sutherland, K., 2006, Experiencing Poverty: The Voices of Low-Income Australians, Towards New Indicators of Disadvantage Project Stage I: Focus Group Outcomes, Social Policy Research Centre, University of New South Wales [Online], Available: http://www.sprc.unsw.edu.au/reports/FinalReportMarch06.pdf [2007, Sep 7].

NOTE: The research is funded by the Australian Research Council and is being conducted in collaboration with some of Australia’s leading community sector agencies—Mission Australia, the Brotherhood of St Laurence, Anglicare (Sydney) and the Australian Council of Social Service (ACOSS). A report on the findings from the two surveys will be released later this year. Further details are available on request from the author.

Peter Saunders is an ARC Australian Professorial Fellow studying the nature and measurement of poverty and inequality, including the impact of community attitudes. He is a former Director of the Social Policy Research Centre (1987–2007) and currently holds a Research Chair in the Centre.

View other articles in this symposium :

Editors’ Introduction Shaun Wilson and Gabrielle Meagher
Inequality in Oral Health in Australia John Spencer and Jane Harford
The Road to Oral Health Policy Innovation in Australia Jenny M. Lewis