Research Project Report
The winning entry for the 2017 FGDP Yorkshire Essay competition
Exploring the barriers faced by homeless people accessing oral healthcare services in Leeds
J.E.Talbot, G.V.A.Douglas, J.I.Csikar
In recent years, the number of people without a home has increased to such a level; homelessness is now a major subject of social and political concern (BDA, 2004). It is difficult in the United Kingdom to measure the number of homeless because of its transient and dynamic nature. People sleeping rough, moving around or hiding away in unsafe housing has resulted beyond simply lacking a roof. Now it encompasses an array of circumstances leading to individuals or families lacking accommodation, which is accessible and physically available to continually inhabit (BDA, 2004; Daly et al., 2001).
Better access to healthcare is a critical component in improving health outcomes for this group but despite efforts to reduce oral health inequalities many obstacles still hinder the homeless. Although attention has been given to general health, dental health issues for the homeless have been overlooked (BDA, 2004). It is widely documented that poor oral health is closely related to certain medical conditions (Edlund et al., 2003; Saitz et al., 2004 and McGuire et al., 2009). The consequence of insufficient access to oral health care and its effects on general health at individual and population levels are vast.
It is widely reported that the homeless face difficulties when accessing and using any healthcare service however there are very few papers published on their oral health service usage. This overlooked area may be one reason why attendance remains low. The BDA (2004) believes different localities across the UK present different sets of barriers to accessing dental services and in 2004 called for more qualitative and quantitative research. Most researchers recognize that the main impediments to oral healthcare services are the cost of dental treatment, anxiety and a low priority compared to other needs (Davies and Burridge, 2013; Coles et al., 2011; Simons et al., 2012; Hill and Remington, 2011; Collins and Freeman, 2007; BDA, 2004; Blackmore et al., 1995).
Davies and Burridge (2013) found 73% of homeless people were not registered with a dentist. Hill and Remington (2000) supported this. Further literature has revealed that many are unconcerned about their dental health (Blackmore et al., 1995; Jago et al., 1984), expressing a lack of perceived treatment need (Gray, 2007). In Leeds, Blackmore et al. (1995) found just over half experiencing dental pain sought treatment. As a result, many wait until they experience acute dental pain leading to emergency treatment (Davis et al., 2011). Previous research demonstrates these people are more anxious, increasingly isolated and vulnerable in comparison to the general population (Collins and Freeman, 2007; Coles et al., 2011).
Above all the literature acknowledges that further qualitative research is needed. The aim of the study was to identify the barriers for homeless people accessing dental care within Leeds. An understanding of these obstacles will aid the dental professionals to make specific adjustments in accordance with the needs of those who are homeless.
This qualitative research involved a pre piloted semi structured questionnaire carried out over 3 weeks with twenty-six participants at St George’s Crypt. The results of the interviews were transcribed and analysed through Excel software.
26 people were interviewed, 23 males and 3 females. Ages ranged from 24 to 66 years. 23 were dentate, 2 partially dentate and 1 edentulous. 22 acknowledged the need and importance of seeing a dentist. 20 described their oral health as very bad. 69% expressed feeling uncomfortable, embarrassed and self-conscious about their appearance. 75% had not seen a dentist in 10years. 2 had attempted to see the dentist but missed appointments causing de-registration. 3 felt unhappy with their interaction with the dentist. 4 were unable to understand dental terms. 11 reported seeking emergency dental care of which 45% had visited the Leeds Dental Institute. 20 were willing to be treated by dental students.
These findings reflect previous studies (Collins and Freeman, 2007; Coles et al., 2009; Hill and Rimington, 2011) by showing homeless peoples’ lifestyle have a negative impact on oral health and in turn a high number fail to attend oral healthcare services. Through this study it became apparent that there are many physical, psychological and attitudinal barriers that homeless people face when accessing oral healthcare services.
The study’s one main weakness is that it comprised a small convenience sample from one locality over a short timeline making it difficult to attribute the effect of demographic differences to perceived barriers. The number studied is not adequately sampled therefore its findings should not be generalized as the norm for all homeless people. The interviews were conducted 1-1 with participants identified by the training coordinator and approached by the researcher resulting in a non-randomised sample. 4 people asked their answers not to be included in the write up. Selection bias may have arisen, recruiting participants from a single locality using a non-probability convenience sampling method; contributing to a reduced sample size and threatening the external validity of the results. Blinding of outcome assessors was not addressed.
However, the data contributes to the overall body of knowledge as seen in previous studies. Despite the small sample size these exploratory findings call for future qualitative and quantitative research. Increased data would allow recruitment of individuals using statistical powers, statistical analysis, increased actual effect size, decrease sample variability and increased precision of outcome measures providing more confident results (Fitzpatrick-Lewis et al., 2011).
The transience nature of the homeless, which became apparent over the three-week period, highlighted shifts in site size and demographic composition of study populations. The researcher worked closely with the training coordinator to overcome this limitation, her knowledge and familiarity with this group helped the participants overcome apprehension and allowed those more reclusive to participate in the study. In addition, the use of an in-person assessment enabled a strong response with majority of participants engaging with the researcher, and responding openly and frankly to the questions.
Whilst Hill and Remington’s study (2011) found low priority as one of the main reasons for poor attendance, this study demonstrated that many homeless people wanted to improve their oral health.
Experience of discomfort, toothache, speaking and difficulty eating due to decayed teeth were expected findings. The majority of participants describing their oral health status as negative reflected this. It may have been beneficial, as in the Scottish study (Coles et al., 2009) to perform an intra-oral exam to see whether the perception of their oral health mirrored the reality.
Participants found it difficult to access dental care because it is difficult to sustain continuity of care, to make appointments in advance and to participate in health improvement activities. As seen in Caton et al (2015), participants wished for more flexible appointments. The chaotic nature of homeless people’s lives, as well as the presence or absence of pain influenced clinic attendance. Maintaining contact is often difficult especially if the household is only accommodated temporarily. The majority of participants had no fixed address or contact number, next of kin or GP details and some admitted they are unable to read and understand appointment reminders and letters. Inadequate oral health literature for both individuals and all types of health professionals contribute to poor access because individuals may not understand the importance of oral health care or their options (Coles et al., 2009).
Through this study, it is apparent barriers and access are very similar. To increase access in oral healthcare services barriers must be dismantled and personal contact utilised. To treat homeless people effectively, dental professionals and the communities they serve must become partners. Future dentists need to be trained to not only be skillful clinicians but cultivators of insights, attitudes and skills providing access to all populations (Beck, 2005). Establishing a detailed needs assessment may help create a more complete understanding of patient circumstances and their journey to reaching good oral health. The literature (Davies and Burridge, 2013; Hill and Remington, 2011; Coles et al., 2009; Blackmore et al., 1995) has shown that recommendations for improved oral health services for homeless people has previously been made however for this to become a reality active participation by local homeless people in its planning and designation needs to be considered.
Previous studies have demonstrated (Coles et al., 2011; Coles et al., 2009, Collins and Freeman, 2007; Wright and Tompkins, 2006) that building health- community partnerships is not easy and involves major time and resource commitments; working across cultures and norms to build trust and understanding (Wright and Tompkins, 2006) between populations. Whilst local communities must realize it has a responsibility to care for this population, the understanding that a patient can exercise control over their care will be an extension of their dental care experience overall. However, the rewards and benefits can be far reaching; an accessible oral healthcare service can have a significant impact; removing pain, improving oral health status and increasing self confidence.