A.) Zola (1973) indicated that there are five social triggers which lead to seeking medical help and could help explain Donald’s presentation. Donald may be experiencing symptoms which could be affecting his ability to work, thus making it difficult to provide for his family. He could possibly be experiencing symptoms which have been impacting his social life. For instance, he may be unable to spend time with friends and family- which could lead to a profound effect on his mental state and thus has required him to seek medical help. In addition, Donald may have been temporising/bargaining i.e. his symptoms have not cleared up over time and has now resulted in him seeking help. Other reasons could include Donald experiencing an interpersonal crisis whereby negative news has motivated Donald to seek medical help and finally, Donald may be experiencing sanctioning, whereby friends and family have advised Donald to seek help in order to resolve his issue.
B.) Demographic factors can have a profound effect on regular dental attendance. The Adult Dental Health Survey (ADHS) in 2009 highlighted that “45% of young adults (aged 25-34) attended for regular check-ups compared to the elderly (aged 65-74) where ~77% attended for regular check-ups”. These statistics could explain Donald’s low dental attendance. Socioeconomic status (SES) can impact dental attendance directly. Individuals with a lower SES can’t afford to visit the dentist regularly and undergo treatment. The ADHS in 2009 highlighted that “17% of adults in routine and manual occupations had treatment both affected and delayed by cost compared to 13% of adults in managerial and professional occupations”. Delaying treatment could mean that these individuals in turn suffer with irreversible and more significant pathology. Females are more likely to attend the dentist (68%) compared to males (54%), this could also explain the fact that Donald’s wife brings their children to appointments opposed to Donald.
Culture can have a large influence on how an individual responds to and thinks about health. Oral health may not be seen as a priority, which may lead to acceptance of symptoms and dental neglect. Other health problems or aspects of life such as; work, money and family/friends take priority. This can therefore lead to reduced attendance to dental appointments. Perceptions of the illness can profoundly affect dental attendance. If missing teeth/caries is seen as a norm in the family, they are less likely to label themselves as ‘ill’ until symptoms develop and affect their daily activities, which could be the reason why Donald’s extended family only attend when in pain. This could also explain anxiety and fear being common symptoms as these individuals will usually require more invasive procedures which involve the use of needles/extractions/drilling (Appukuttan, 2016). Past experiences/proxy experiences can contribute to expectations of treatment & negative experiences. For example, being denied treatment from several dentists could de-motivate the individual to continue seeking care and lead to reduced attendance.
C.) The availability of the service can directly affect the family’s access to care. For example, individuals who are unsuccessful in obtaining appointments with the dentist are less likely to continue seeking care. The GP patient survey from July to September 2014, highlighted that “young adults (aged 25-34) were less likely to get an NHS dental appointment, with 90.2% succeeding, compared to the elderly (aged 65-74) who were more likely to get an appointment, with 96.5% succeeding”. The availability of care can also be described by the inverse care law; whereby good dental care is inversely proportional to the need of the population, consequently the most deprived areas experience the highest levels of decay. The survey of dental health of five-year-old children in Yorkshire and Humber (2011), reported that the most deprived areas had a DMFT more than 3 times when compared to the least-deprived areas.
Dental practices that are harder to access, for example, long travel times can lead to lower attendance. This is particularly important for patients who experience mobility problems and those that need to take public transportation. The cost of treatment can be a major barrier to accessing regular dental care and can also influence the type of treatment as well as delaying required treatment. The ADHS in 2009, reported that “26% of adults said the type of treatment they opted for had been affected by the cost and 19% delayed treatment due to costs”. Practices that operate via the ‘fee for item service’ may encourage over-treatment and lead to families with a low SES avoiding the service. Dentists may also be discouraged from providing public dentistry if reimbursement is poor, which can lead to reduced availability of dentists. The organisation of the service can influence the utilisation, for example, opening/closing times and appointment systems require patients to take time off work, which in Donald’s case may not be possible and would prefer drop in services that require no appointments. Also, if the service is not accepting patients, this could mean seeking private treatment which ultimately costs more and may not be feasible for Donald and his family. Finally, the relationship between patient desires and characteristics of the service can influence access to care. For instance, staff may hold negative views toward certain patient groups such as elderly, psychological problems etc. which can be intimidating and discourage them from using the service altogether.
Q2.
A) Donald’s previous dental attendance should not influence the treatment decision. It is the Dentist’s professional, moral and legal obligation to gain consent from all competent patients prior to commencing treatment, without it, dental treatment can legally be seen as assault (Dougall and Fiske, 2008) Informed consent provides the patient with information regarding the nature and purpose of treatment including the risks, benefits and alternative treatments (which also includes no treatment). This should be supplemented with information leaflets written in understandable/jargon-free language so that the patient can take the information away from the clinical setting and use it to take time to weigh up a decision. This decision should be entirely voluntary and should not be interfered by friends/family as well as healthcare professionals. Finally, the Dentist should respect the patient’s autonomy, even in cases where the clinician deems the treatment option to not be in the patient’s best interests (Dougall and Fiske, 2008).
B) Obtaining consent is not merely the process of getting a patient to sign a form. Consent requires a partnership between the dentist and patient and it is a process which requires detailed explanation and time for the patient to understand and retain the information in order to weigh up choices and eventually communicate their decision (Dougall and Fiske, 2008).
In order to ensure the consent is valid, the clinician must begin by understand what the patient currently knows about their condition and clarify by explaining the information related to the clinical condition in an understandable/jargon-free language. This will then be followed up by outlining the various treatment options, including no treatment as an option. The risks (rare and common) and benefits of the treatment options should also be explained, it is important for the Dentist to facilitate informational leaflets summarising what had been discussed as “40-80% of information provided by healthcare professionals is forgotten after the consultation” (Kessels, 2003). Inviting the patient to ask questions and summarise what has been discussed will clarify any misunderstandings. It is important for the Dentist to respect the autonomy of the patient’s treatment decision and for the dentist to obtain written consent, recording the options (and relevant risks/benefits) and preferred treatment in patient notes.
C.) GDC standard 2.1 outlines the need to give patients time to consider information (GDC: Standards For The Dental Team, 2013). Taking time to consider the risks of dental procedures is important as it allows the patient to actively process information and therefore acquire a better understanding of the treatments proposed. Research conducted on adult literacy in America highlighted the gap in patient’s knowledge of treatment risks. It was identified in this study that “60% of hospital patients could not understand information listed on a consent form and that these patients preserved only 12% of what was discussed in consultations” (Kirch et al., 1993) posing risks that could significantly impact one’s health, therefore, taking time to consider risks will help the patient understand anything missed or forgotten in the consultation. The stigma associated with poor literacy creates a barrier to understanding risks associated with treatments, according to the National Literacy Trust, (2017) “5.1 million adults in England have a literacy level at or below an 11-year-old”. It is therefore important for the clinician to provide informational leaflets that will allow the patient to make an informed decision. Also, this is beneficial for the clinician obtaining consent, as taking time to consider and understand information is an indication that the patient has capacity, which is required for consent to be valid.
D)i.) Numeracy mediates patients understanding of statistical information, which is vital in perceiving risk and decision making. Patients with low numeracy are often older adults and are more likely to be disadvantaged when understanding medical risk information (Galesic, Garcia-Retamero and Gigerenzer, 2009). When understanding common side effects, “34.2% of patients understood verbal explanations compared to 8.1% when explained numerically” (Roeser., et al 2012). However, it has been noted that understanding was significantly improved when numerical information was presented by using absolute risk reduction (ARR) opposed to relative risk reduction (RRR) and subjects with higher numeracy level were more accurate when estimating RRR (Galesic, Garcia-Retamero and Gigerenzer, 2009)
ii) Experimental tests by Galesic et al (2009) identified that Icon arrays (graphical representation of risk using icons to symbolise individuals who are affected by a certain risk) improved the accuracy of RRR and were useful for participants whose numeracy was low compared to the average of their retrospective groups in understanding medical risks.
There are also a variety of techniques of communicating risks for patients that present with learning disabilities, including Makaton, which is a system that uses symbols/signs with speech/written word to provide a visual illustration of language and covers common dental procedures such as extractions, radiographs, local anaesthesia etc. Makaton has shown to increase participation in interactions, which is required for consent. Makaton is especially useful as learning disabilities are very common, with “580,000-1,750,000 people in the UK having mild to moderate learning disability” (Dougall and Fiske, 2008).
Singnalong is also a technique used for patients with learning disabilities and is a system which uses body language, facial expressions and tone of voice to reinforce signed and spoken messages (Dougall and Fiske, 2008).
The ability to read is essential in understanding information, for example, on a consent form. Widgit software has been designed to help develop literacy in adults with learning disabilities through the use of pictures/symbols and words (Dougall and Fiske, 2008).
Talking mats is also a tool used for patients with communication difficulties and it uses pictures/symbols as the basis of communication. Research has shown that talking mats improves the quantity and quality of information gained by patients and is an excellent tool in determining if patients have capacity to give consent (Dougall and Fiske, 2008).
Q3.
A.)Stigma is the name of this psycho-social process and refers to a trait that society considers different from the norm, and according to Goffman’s classification, poor dental health is an example of stigma of the body. Individuals who experience stigma are treated differently from the rest of society and experience negative feelings of shame, rejection and devaluation (Scambler, 2009). There are 4 main domains of stigma; the patient experiences fear and avoids social encounters which leads to exclusion and isolation from day to day activities; the person values them self lowly and feels a sense of shame about their appearance making them embarrassed to be in social situations and can prevent the individual getting a job; the person is discriminated in society due to prejudice- treated differently because of their dental appearance; and finally people are afraid to disclose information regarding their dental health which can prevent people seeking professional help, this in turn delays treatment and impairs recovery. These features create a cycle of felt stigma (the feeling of being stigmatised e.g. the person looks ‘dangerous’ because they have missing teeth), enacted stigma (actually being discriminated against e.g. excluded from social events because you look dangerous) and self-stigma (whereby the individual internalises/accepts the negative views).
B.) Extracting teeth can have profound effects on both function and the appearance of the individual which can in turn, lead to a negative impact on Donald’s psycho-social well-being. Edentulism is associated with several biological factors including ageing, dental neglect and trauma. Furthermore, edentulism can be associated with negative social stereotypes such as poverty and incarceration.
The ADHS, 2009 reported that “26% of adults said the type of treatment they opted for had been affected by the cost and 19% delayed treatment due to costs”. A study had also concluded that individuals with missing teeth were perceived socially inferior (less attractive, less educated, more aggressive and less trustworthy) when compared to a person with a full dentition (Willis, Esqueda and Schacht, 2008) essentially creating a cycle of prejudice and discrimination which can lead to self-stigma. According to Goffman’s classification, poor oral health is categorised as ‘stigma of the body’ (stigma is well known/evident) which can lead to Donald experiencing self-stigma as Donald is aware that his poor dental health is stigmatised by society and eventually accepts the stereotypes associated with his condition. This can lead to self-limiting behaviour, for example, isolating/excluding himself from social and day-to-day activities such as spending time with friends/family and can prevent Donald from getting a job. Internalising the stigma can also prevent Donald from seeking help which can delay treatment and eventually exacerbate the problem.