How Do Dentists Perceive Poverty and People on Social Assistance? A Qualitative Study Conducted in Montreal, Canada

Dentistry's social contract and dental students' moral inclusiveness

BACKGROUND

Under dentistry's social contract with the public, dental professionals have a social responsibility to address the oral health needs of the population at large. However, dental education places little emphasis on such moral commitments. By ascertaining dental students' stance regarding these notions, we may be able to inform changes in dental education. This paper thus explores dental students' comprehension of dentistry's social contract using the concepts of moral inclusion, moral community and empathy.

METHODS

A cross-sectional online survey collected information from undergraduate dental students at the Faculty of Dentistry, University of Toronto (N = 430). Moral inclusion was assessed through the breadth of students' moral community by computing a "moral inclusion score" (MIS) from Likert scale responses to statements that asked students about their duty of care for different population groups, wherein a higher MIS indicated a broader moral community and in turn greater moral inclusiveness. Empathy was assessed using Likert scale responses to statements that gauged the extent to which students understood the effect of social determinants on people's health. Association of the MIS with environmental, institutional and student-related factors was also investigated using non-parametric tests and linear regression.

RESULTS

The survey yielded a response rate of 51.4% (n = 221). Overall, students in this sample were morally inclusive and displayed empathy. Regression results showed that the MIS was most strongly associated with choosing a small town/rural area as a future practice location (β = 4.76, 95% CI: 0.52, 9.01) and viewing patients as consumers (β = -3.71, 95%CI: -7.13, -0.29).

CONCLUSION

Students in this sample made morally inclusive choices, which implied that they had a basic understanding of the obligations under dentistry's social contract. Improving knowledge and experience with regards to addressing the social and economic determinants of oral health and access to oral health care may positively influence students' perceptions of their professional duties under the social contract.

Conceptualisations of the social determinants of health among first-year dental students

BACKGROUND

Social conditions have a significant impact on the health of individuals and populations. While the dental curriculum is focused on teaching students about the diseases that affect the dentition and oral structures from a biomedical perspective, education about the social determinants of health is frequently regarded as less important. Thus, it occupies a smaller and disconnected part of the dental curriculum. The aim of this study was to explore the ways dental students conceptualised the social determinants of health after one year in dental school.

METHODS

Reflective statements written by first year dental students at the end of the first year of study were collected. This qualitative study has an interpretivist basis and a thematic analysis of the reflections was conducted by two researchers. Metzl's structural competencies were used as a further analytic device.

RESULTS

Four inter-related themes were identified: First, professional attitudes taken up by students influence their conceptions. Second, structural barriers to students understanding social determinants of health generate partial understandings. Thirdly, the social gulf that exists between the student body and people of different circumstances provides context to understanding the student's perspectives. Finally, we described how students were learning about the social determinants of health over the academic year.

CONCLUSIONS

Dental students face several challenges when learning about the social determinants of health, and translating these learnings into actions is perhaps even more challenging. Metzl's structural competencies provide a framework for advancing students' understandings. One of the most important findings of this research study is that coming to an understanding of the social determinants of health requires sustained attention to social theories, practical experiences as well as institutionalised attitudes that could be achieved through an intentional curriculum design.

How are the social determinants of health being taught in dental education?

INTRODUCTION

The social determinants of health that influence how wellness and illness are experienced within society must be a core component of dental curricula where aspiring dental professionals are taught about the aetiology and social history of dental diseases. Through this scoping review, we examine the current approaches that have been employed to incorporate the social determinants of health within dental curricula.

METHODS

Using a scoping review methodology, we searched the databases Scopus, PubMed, and Embase using keywords relevant to the social determinants of health and dental education.

RESULTS

Following screening and sorting, 36 articles were included within this review. The majority of the articles described research that evaluated outcomes of educational interventions with relevance to the social determinants of health. The remainder of the included studies discussed attitudes and readiness relative to the social determinants of health and how this core competency could be taught effectively.

CONCLUSION

The included literature revealed that the social determinants of health frequently are not the focus of educational activities in dental curricula, with students frequently having little active guidance on how they might make sense of their educational experiences in this domain. The socioeconomic, cultural, political, geographic, and structural barriers that contribute to patients being impacted by the social determinants of health should be explicitly addressed and discussed with students as a foundation element of the dental curriculum.

[Oral health inequalities: Determinants of access to prevention and care in France]

INTRODUCTION

Oral diseases are unequally distributed according to a social gradient, which now constitutes a major public health problem. Acting against oral health inequalities requires a better understanding of the underlying mechanisms in order to identify the appropriate solutions to improve access to oral health promotion and dental care for deprived populations.

METHODS

A patient-centered model of health care access, describing the ideal interactions between individuals and the health care system was applied to the field of oral health in the French context. This model defines access to health care as the result of interactions between individuals and the health care system, in which health needs are perceived, health care is sought, health care structures are accessed and effectively used. Analysis is based on quantitative and qualitative bibliographic data acquired through an explanatory sociological approach.

RESULTS

Socially deprived populations face many barriers preventing their access to dental care: the need for dental care is not necessarily perceived, and, when perceived, dental care is not immediately sought, accessibility to dental care structures is difficult and dental attendance is erratic.

CONCLUSION

This review provides information to decision-makers in order to support regional health policies and to help implement public health strategies according to the principle of proportionate universalism. Two axes for action were identified, namely to integrate oral health promotion interventions within health promotion programmes and to gradually reorganize the dental care system to make it more accessible to everyone.

Assessing the relationship between dental appearance and the potential for discrimination in Ontario, Canada

Poor oral health is influenced by a variety of individual and structural factors. It disproportionately impacts socially marginalized people, and has implications for how one is perceived by others. This study assesses the degree to which residents of Canada's most populated province, Ontario, recognize income-related oral health inequalities and the degree to which Ontarians blame the poor for these differences in health, thus providing an indirect assessment of the potential for prejudicial treatment of the poor for having bad teeth. Data were used from a provincially representative survey conducted in Ontario, Canada in 2010 (n=2006). The survey asked participants questions about fifteen specific conditions (e.g. dental decay, heart disease, cancer) for which inequalities have been described in Ontario, and whether participants agreed or disagreed with various statements asserting blame for differences in health between social groups. Binary logistic regression was used to determine whether assertions of blame for differences in health are related to perceptions of oral health conditions. Oral health conditions are more commonly perceived as a problem of the poor when compared to other diseases and conditions. Among those who recognize that oral conditions more commonly affect the poor, particular socioeconomic and demographic characteristics predict the blaming of the poor for these differences in health, including sex, age, education, income, and political voting intention. Social and economic gradients exist in the recognition of, and blame for, oral health conditions among the poor, suggesting a potential for discrimination amongst socially marginalized groups relative to dental appearance. Expanding and improving programs that are targeted at improving the oral and dental health of the poor may create a context that mitigates discrimination.

Ideological roadblocks to humanizing dentistry, an evaluative case study of a continuing education course on social determinants of health

BACKGROUND

Front line providers of care are frequently lacking in knowledge on and sensitivity to social and structural determinants of underprivileged patients' health. Developing and evaluating approaches to raising health professional awareness and capacity to respond to social determinants is a crucial step in addressing this issue. McGill University, in partnership with Université de Montréal, Québec dental regulatory authorities, and the Québec anti-poverty coalition, co-developed a continuing education (CE) intervention that aims to transfer knowledge and improve the practices of oral health professionals with people living on welfare. Through the use of original educational tools integrating patient narratives and a short film, the onsite course aims to elicit affective learning and critical reflection on practices, as well as provide staff coaching.

METHODS

A qualitative case study was conducted, in Montreal Canada, among members of a dental team who participated in this innovative CE course over a period of four months. Data collection consisted in a series of semi-structured individual interviews conducted with 15 members of the dental team throughout the training, digitally recorded group discussions linked to the CE activities, clinic administrative documents and researcher-trainer field notes and journal. In line with adult transformative learning theory, interpretive analysis aimed to reveal learning processes, perceived outcomes and collective perspectives that constrain individual and organizational change.

RESULTS

The findings presented in this article consist in four interactive themes, reflective of clinic culture and context, that act as barriers to humanizing patient care: 1) belief in the "ineluctable" commoditization of dentistry; 2) "equal treatment", a belief constraining concern for equity and the recognition of discriminatory practices; 3) a predominantly biomedical orientation to care; and 4) stereotypical categorization of publically insured patients into "deserving" vs. "non-deserving" poor. We discuss implications for oral health policy, orientations for dental education, as well as the role dental regulatory authorities should play in addressing discrimination and prejudice.

CONCLUSION

Humanizing care and developing oral health practitioners' capacity to respond to social determinants of health, are challenged by significant ideological roadblocks. These require multi-level and multi-sectorial action if gains in social equity in oral health are to be made.

Perceived barriers to healthcare for persons living in poverty in Quebec, Canada: the EQUIhealThY project

Introduction

Ensuring access to timely and appropriate primary healthcare for deprived patients is an issue facing all countries, even those with universal healthcare systems. There is a paucity of information on how patients living in a context of material and social deprivation perceive barriers in the healthcare system. This study combines the perspectives of persons living in poverty and of healthcare providers to explore barriers to responsive care for underserved persons with a view to developing equity-focused primary care.

Methods

In this participatory action research we used photovoice, together with a method known as ‘merging of knowledge and practice’ developed by ATD Fourth World, an international community organization working to eradicate poverty. The study was conducted in two teaching primary care practices in the Canadian province of Quebec. Participants consisted of 15 health professionals and six members of ATD Fourth World; approximately 60 group meetings were held. Data were analyzed through thematic analysis, in part with the involvement of persons living in poverty.

Results

Three main barriers to responsive care in a context of poverty were highlighted by all participants: the difficult living conditions of people living in poverty, the poor quality of interactions between providers and underserved patients, and the complexity of healthcare system organization and functioning.

Conclusion

Our research revealed that unhealthy living conditions prevent persons living in poverty from accessing quality healthcare and maintaining good health. Also, the complexity of the healthcare system’s organization and functioning has a negative impact on the interactions with healthcare providers. Changes in policy and practice are needed to address those barriers and to achieve greater equity and provide more responsive care for persons living in poverty.

Medical residents reflect on their prejudices toward poverty: a photovoice training project

BACKGROUND

Clinicians face challenges in delivering care to socioeconomically disadvantaged patients. While both the public and academic sectors recognize the importance of addressing social inequities in healthcare, there is room for improvement in the training of family physicians, who report being ill-equipped to provide care that is responsive to the living conditions of these patients. This study explored: (i) residents' perceptions and experience in relation to providing care for socioeconomically disadvantaged patients, and (ii) how participating in a photovoice study helped them uncover and examine some of their prejudices and assumptions about poverty.

METHODS

We conducted a participatory photovoice study. Participants were four family medicine residents, two medical supervisors, and two researchers. Residents attended six photovoice meetings at which they discussed photos they had taken. In collaboration with the researchers, the participants defined the research questions, took photos, and participated in data analysis and results dissemination. Meetings were recorded and transcribed for analysis, which consisted of coding, peer debriefing, thematic analysis, and interpretation.

RESULTS

The medical residents uncovered and examined their own prejudices and misconceptions about poverty. They reported feeling unprepared to provide care to socioeconomically disadvantaged patients. Supported by medical supervisors and researchers, the residents underwent a three-phase reflexive process of: (1) engaging reflexively, (2) break(ing) through, and (3) taking action. The results indicated that medical residents subsequently felt encouraged to adopt a care approach that helped them overcome the social distance between themselves and their socioeconomically disadvantaged patients.

CONCLUSIONS

This study highlights the importance of providing medical training on issues related to poverty and increasing awareness about social inequalities in medical education to counteract prejudices toward socioeconomically disadvantaged patients. Future studies should examine which elective courses and training could provide suitable tools to clinicians to improve their competence in delivering care to socioeconomically disadvantaged patients.

The american dental dream

The American Dental Dream-the cultural desire for straight, white teeth-is difficult, if not impossible, for poor and working-class people to achieve. Using ethnographic fiction, autoethnography, poetry, and qualitative interviewing, I brush away the taken-for-granted assumptions about teeth. I explore the personal, relational, and structural consequences of this cultural desire, and show how social class writes itself on our bodies. I write these culture-centered teeth tales to show how one might cope with their teeth.