A rapid review of barriers to oral healthcare for vulnerable people

El-Yousfi, Sarab; Jones, Kate; White, Sandra; Marshman, Zoe

doi:10.1038/s41415-019-0529-7

Research
Published: 26 July 2019

A rapid review of barriers to oral healthcare for vulnerable people

Sarab El-Yousfi¹,
Kate Jones²,
Sandra White² &
…
Zoe Marshman¹

British Dental Journal volume 227, pages 143–151 (2019)Cite this article

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Abstract

Introduction People from vulnerable groups have higher levels of untreated dental disease compared to the general population, yet often experience barriers to accessing care. Difficulties accessing oral healthcare services have been suggested as one of the pathways that contribute to oral health inequalities.

Aim To conduct a rapid review of current literature related to barriers to oral healthcare for people from vulnerable groups.

Methods Electronic searching u sing MEDLINE via Ovid, covering articles from 2007 to 2017, and limited to the English language. Publication types included primary and secondary evidence from peer-reviewed journals and reports.

Results From a total of 536 records, 308 full-text articles were included in the final review. Barriers were summarised at the individual, organisational and policy levels. Common barriers across all vulnerable groups included lack of affordability, difficulties accessing care, lack of availability of appropriate care, and lack of public funding for specialised services. In addition, specific barriers were identified for certain groups. Potential solutions included the provision of training and information to patients and carers about oral health and accessing dental services, training dental professionals in caring for vulnerable groups, and better use of skill mix and guidance to ensure publicly-funded dental services are commissioned to meet the needs of vulnerable groups.

Conclusion This rapid review identified barriers to dental care for vulnerable groups at individual, organisational and policy levels to inform policymakers and commissioners.

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Key points

Describes the common barriers to accessing oral healthcare experienced across all vulnerable groups.
Argues that barriers to oral healthcare for people from vulnerable groups exist at individual, organisational and policy levels.
Identifies and summarises possible solutions to address these barriers.

Introduction

Various definitions for vulnerability have been proposed, however there remains little consensus.¹^,² A broad definition, suggested by Aday,³ describes vulnerable populations as social groups who are at greater risk of poor physical, psychological and/or social health due to their social status. These marginalised groups often experience barriers to gaining access to oral healthcare.⁴ They are also disproportionally affected by dental diseases.⁵ Previous studies have shown certain groups to have higher levels of dental caries than the general population, such as individuals with special needs,⁶ certain ethnic minority groups,⁷^,⁸ people experiencing homelessness,⁹ people of low socioeconomic status,¹⁰^,¹¹ and rural communities,¹² among others.

Despite a greater need for dental treatment, vulnerable individuals are less likely to receive routine dental care. This double disadvantage of poorer oral health and difficulties accessing dental services results in an inordinate burden of disease and potential adverse oral health outcomes. Indeed, difficulties accessing dental services have been suggested as one of the pathways that contribute to oral health inequalities.¹³ Access to primary oral healthcare services contributes to good oral health through the provision of advice, early diagnosis, prevention and treatment of oral disease.¹⁴

Given the need to improve access to oral healthcare for vulnerable groups and reduce inequalities, a better understanding of the barriers they experience is needed to improve the provision and commissioning of these services. This review aims to describe the current literature related to barriers to oral healthcare for people from vulnerable groups.

Method

A rapid review method was chosen. Rapid reviews are an emerging type of review used to inform health-related policy, particularly when information is required in a short time frame.¹⁵^,¹⁶ A rapid review has been defined as:

'A type of systematic review in which components of the systematic review process are simplified, omitted or made more efficient in order to produce information in a shorter period of time, preferably with minimal impact on quality. Further, they involve a close relationship with the end-user and are conducted with the needs of the decision-maker in mind'.¹⁷

To ensure the rapidity of the review methodological approaches were used, such as: searching fewer databases, limiting the use of grey literature, restricting the types of studies included, limiting hand-searching of reference lists and journals, using a narrow time frame, involving only one reviewer, and limiting risk of bias assessment.¹⁷

In this review electronic database searches were carried out using MEDLINE via Ovid, covering articles from 2007-2017. The search strategy included the following terms: oral/dental health, oral/dental care, oral/dental hygiene, dental health services, challenges, barriers, access, hindrance, impediment, disabled persons, intellectual disability, special care, special needs, elderly, assisted living, institutional, care homes, nursing homes, physically challenged, mental disorders, vulnerable populations, underserved, homeless, refugees, prisoners, ethnic, low-income, social class, and socioeconomic. Three separate searches were conducted, each focusing on different groups of vulnerable people. The complete search strategy is available in Supplementary Information 1 (online only). The publication types included in the search were primary and secondary evidence from peer-reviewed journals and reports. The search was restricted to publications in English. The results of all three searches were exported into a reference manager. Duplicates were then recorded and removed before the titles and abstracts of the remaining articles were reviewed. Where titles and abstracts appeared to be relevant, the full text was obtained for inclusion in the review. Reference list searching was also conducted.

For each included article the barriers, as identified in the publication, were extracted, collated and summarised for each vulnerable group, the full table is available in Supplementary Information 2 (online only). Where stated, potential solutions to overcome these barriers were also summarised.

Results

The search yielded 536 records. After removal of duplicates, the remaining 514 titles and abstracts were screened for eligibility, resulting in 220 documents being excluded. Reference list searching identified a further 14 records leading to 308 full-text articles being included in the final review. A PRISMA flowchart of the literature search from MEDLINE via Ovid is provided in Figure 1.

The majority of the included literature was from peer-reviewed journals, with articles from 34 countries; the full list is available in Appendix 1. From the literature the main vulnerable groups were categorised based on sociodemographic characteristics such as: 1) people of low socio-economic status; 2) racial or ethnic groups; 3) migrants; 4) refugees; 5) people living in rural areas; 6) older people living in residential care; 7) older people living in their own homes; 8) people who are homeless; 9) people who are travellers; and 10) people who are in prison. The other groups related to people with specific conditions such as: 1) HIV; 2) autism; 3) blindness; 4) deafness; 5) epilepsy; 6) Down's syndrome; 7) Parkinson's disease; 8) medically-compromised; 9) mental illness; 10) schizophrenia; 11) learning disabilities; 12) physical disabilities; and 13) children with disabilities. Finally, the last group was patients treated specifically by the speciality of special care dentistry (SCD).

Summary of the main common barriers

While the literature on barriers to oral healthcare for vulnerable people was summarised by category, there were several common barriers noted across most of them. These barriers have been summarised at the level of the individual person or patient, the level of the dental service organisation and at the higher policy level (Box 1).

Individual-level barriers common across vulnerable groups

Most of the literature investigated barriers at the level of the individual. The most common individual-level barrier was that services were unaffordable or perceived to be unaffordable for the public, patients, parents or carers.¹⁸^,¹⁹^,²⁰^,²¹^,²²^, ²³^,²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²^,³³^,³⁴^,³⁵^,³⁶^,³⁷^,³⁸^,³⁹^,⁴⁰^,⁴¹^,⁴²^,⁴³^,⁴⁴^,⁴⁵^,⁴⁶^,⁴⁷^,⁴⁸^,⁴⁹^,⁵⁰^, ⁵¹^,⁵²^,⁵³^,⁵⁴^,⁵⁵^,⁵⁶^,⁵⁷^,⁵⁸^,⁵⁹^,⁶⁰^,⁶¹^,⁶²^,⁶³^,⁶⁴^,⁶⁵^,⁶⁶^,⁶⁷^,⁶⁸^,⁶⁹^,⁷⁰^,⁷¹^,⁷²^,⁷³^,⁷⁴^,⁷⁵^,⁷⁶^,⁷⁷^,⁷⁸^, ⁷⁹^,⁸⁰^,⁸¹ Lack of affordability was not confined to the literature on people of low socioeconomic status but was an issue across most vulnerable groups and from most countries. This financial barrier includes the direct cost of the service and indirect costs such as cost to the carers and cost of transportation. This was compounded by the lack of knowledge of the cost of available services.⁵²^,⁵³^,⁵⁴^,⁸²^,⁸³ In terms of transportation, it was not only the cost of transportation that was a barrier but difficulties in finding suitable transportation.²⁰^,³⁵^,³⁸^,⁴¹^,⁴⁵^,⁴⁹^,⁵¹^,⁵³^,⁷³^,⁷⁶^, ⁷⁸^,⁸⁰^,⁸²^,⁸⁴^,⁸⁵^,⁸⁶^,⁸⁷^,⁸⁸^,⁸⁹^,⁹⁰^,⁹¹^,⁹²

People from various vulnerable groups were said to perceive oral health as a low priority due to other daily difficulties in their lives and other comorbidities.¹⁹^,²²^,⁴⁰^,⁵¹^,⁶²^,⁹¹^,⁹³^,⁹⁴^,⁹⁵^,⁹⁶^,⁹⁷^,⁹⁸^,⁹⁹ Low levels of oral health literacy were cited for many groups,²³^,⁴³^,⁵⁹^,⁶¹^,⁶⁷^,⁶⁹^,⁸³^,¹⁰⁰^,¹⁰¹^,¹⁰²^,¹⁰³^,¹⁰⁴^,¹⁰⁵ which has been described as the ability to access or process information to improve oral health. Related to this, people were found to lack knowledge of what services were available and how to make appointments.³³^,⁴²^,⁵²^,⁵⁵^,⁵⁹^,⁶¹^,⁶⁵^,⁷²^,⁹⁵^,¹⁰⁶ Previous difficulties accessing dental care were cited as barriers to accessing services in the future.³⁹^,⁴¹^,⁶⁴^,⁸⁴^,¹⁰⁷ Difficulties were also identified in keeping appointments due to health problems,⁵¹^,⁶⁵^,⁹²^,¹⁰⁸^,¹⁰⁹^,¹¹⁰ getting time off work, or lack of a carer.²³^,²⁷^,³⁰^,³⁸^,⁷³^,⁷⁶^,⁸¹^,¹¹¹^,¹¹²^,¹¹³ Language or communication difficulties were common barriers, with specific problems highlighted for groups such as those from minority ethnic groups, refugees, migrants, those with hearing impairments or mental illness.²⁰^,³⁸^,⁴²^,⁴³^,⁵¹^,⁶⁵^,⁶⁷^,⁷⁶^,⁸¹^,⁸²^,⁸³^,⁹⁰^,¹¹³^,¹¹⁴^,¹¹⁵^,¹¹⁶^,¹¹⁷^,¹¹⁸^,¹¹⁹^,¹²⁰^,¹²¹ Dental fear and anxiety,²²^,³⁰^,³³^,⁴¹^,⁴⁸^,⁴⁹^,⁵³^,⁶³^,⁶⁵^,⁷⁸^,⁹¹^,⁹⁴^,⁹⁵^,¹⁰³^,¹⁰⁵^,¹⁰⁶^,¹¹²^,¹²²^,¹²³^,¹²⁴^,¹²⁵^,¹²⁶^,¹²⁷^,¹²⁸ and a perceived negative attitude from the dental workforce⁵¹^,⁹²^,¹⁰³^,¹²⁴ were common individual-level barriers identified across vulnerable groups.

Organisational-level barriers common across vulnerable groups

The most common organisation-level barrier was the lack of availability of dental care to meet the needs of vulnerable groups including routine, preventive, urgent and specialised care. ³⁰^,³²^,³³^,⁴²^,⁴³^,⁴⁴^,⁵¹^,⁵⁵^,⁵⁷^,⁶⁰^,⁶⁵^,⁶⁶^,⁸⁴^,⁸⁵^,¹⁰³^,¹⁰⁶^,¹¹³^,¹¹⁵^,¹¹⁹^,¹²⁰^,¹²⁵^,¹²⁷^, ¹²⁹^,¹³⁰^,¹³¹^,¹³²^,¹³³^,¹³⁴ This lack of availability was said to lead to long waiting times.²¹^,⁴²^,⁶⁷^,⁶⁸^,⁷¹^,⁷⁴^,⁸⁰^,⁸⁴^,¹¹⁶^,¹¹⁸^,¹²⁵^,¹³⁰^,¹³¹^,¹³²^,¹³⁵ Referral pathways between services were also stated to be difficult to negotiate for organisations involved in the care of vulnerable groups.¹²⁰^,¹³⁶ The literature found poor transition arrangements to be a barrier; for example, moving from services for children to adults or for people moving from living at home to residential care.⁶⁵^,¹³⁴^,¹³⁷^,¹³⁸^,¹³⁹

Some organisation-level barriers mirrored the individual barriers described above, such as insufficient information provided by organisations to individuals in appropriate formats,³⁸^,⁴¹^,⁴⁴^,⁷⁴^,⁸²^,¹⁴⁰ communication difficulties during dental care,⁶²^,⁶⁵^,¹¹⁶^,¹¹⁸^,¹⁴¹ and lack of cultural or disability awareness among the dental workforce.⁸³^,¹⁴² Dental professionals and other healthcare professionals involved were found to lack confidence and training in treating people from vulnerable groups.⁵⁹^,⁶⁹^,⁷⁴^, ⁸⁰^,⁹¹^,¹⁰³^,¹¹³^,¹²⁴^,¹²⁵^,¹⁴⁰^,¹⁴³^,¹⁴⁴^,¹⁴⁵^,¹⁴⁶ Similarly, carers and other health, social, education or community services were said to lack knowledge about key oral health messages and ways to access dental services.⁶⁵^,⁶⁹^,¹⁰³^,¹⁰⁹^,¹¹⁰^,¹³⁴^,¹⁴⁷^,¹⁴⁸^,¹⁴⁹^,¹⁵⁰

Finally, physical barriers to accessing dental care were cited including location of services (and appropriate transport to them), lack of car parking, as well as physical barriers within the dental setting such as lack of handrails, lack of suitable toilet facilities and wheelchair inaccessibility into and within the dental practice.⁵⁹^,⁶³^,⁶⁸^,,⁷⁰^,⁷²^,⁷⁴^,⁷⁶^,⁷⁷^,⁷⁸^,⁷⁹^,⁸¹^,⁹⁰^,⁹²^,⁹⁶^,¹¹³^,¹²⁴^, ¹⁵¹^,¹⁵²^,¹⁵³

Policy-level barriers common across vulnerable groups

Policy-level barriers were less commonly referred to in the literature, although three types were identified. The main policy-level barrier was a lack of public funding for dental services for vulnerable groups.³⁰^,³²^,³³^,³⁵^,³⁸^,³⁹^,⁴⁰^,⁴¹^,¹⁰³^, ¹⁰⁶^,¹¹²^,¹¹⁵^,¹²⁵^,¹²⁹^,¹³³^,¹⁵⁴^,¹⁵⁵^,¹⁵⁶ The level of public funding varied between countries, changed over time and varied between different groups but was a recurring barrier cited. The second main policy-level barrier was a lack of integration between dental and other health, social, education or community services.⁶⁵^,¹²⁸^,¹⁴⁷^,¹⁵⁰ The third policy-level barrier was that dental services were not commissioned based on oral health needs assessments so were not of sufficient capacity or design to meet the needs of vulnerable groups.

Specific barriers identified for vulnerable groups

In addition to the common barriers described above, specific barriers were identified for certain vulnerable groups (Table 1). These barriers were also categorised as individual level, organisational level and policy level.

Table 1 Barriers specific for different vulnerable groups

Full size table

Summary of the main solutions

While the main purpose of the rapid review was to identify barriers to dental care for vulnerable groups, most of the papers included provided some potential solutions to overcome the barriers described. The solutions proposed in the literature can be summarised as:

1.
Provide training and information to patients, parents and carers about improving oral health and ways to access dental services
2.
Improved undergraduate and postgraduate dental training, including outreach training with vulnerable groups to facilitate this training and increase availability of dental services more generally
3.
Use a range of dental care professionals to ensure an appropriate skill mix for addressing the oral healthcare needs of vulnerable groups
4.
Implementation of guidance and pathways of care that meet the needs of vulnerable people and ensure equality of access. These publicly-funded dental services should include routine dental services with a preventive focus and provision of care to address urgent care needs and specialist services. The dental services should be integrated with other health, social and community care services to provide seamless care pathways
5.
Implementation of policies to address the broad structural determinants of oral health.

Box 1 Summary of the main common barriers

Individual level:

Services unaffordable or perceived to be unaffordable for the public, patients and patients/carers
Lack of appropriate knowledge of what services are available and their cost
Difficulties with obtaining affordable and appropriate transport
Oral health not perceived as a priority for patients or carers due to other daily difficulties
Low levels of oral health literacy
Previous difficulties accessing dental care
Language or communication difficulties
Perceived negative attitude from dental workforce
Dental fear and/or anxiety
Difficulties making and keeping appointments due to health problems, getting time off work or lack of a carer.

Organisational level:

Lack of availability of routine, preventive, urgent and specialised care
Insufficient appropriate informatioln provided to patients, the public, parents and carer
Lack of confidence and training of dental professionals in treating patients from vulnerable groups
Communication difficulties with patients and carers
Lack of cultural or disability awareness
Physical barriers to accessing dental care
Lack of knowledge among carers and other health, social, education or community services
Poor transition arrangements e.g. Child to adult services or home dwelling to institutional.

Policy level:

Lack of public funding for dental services for vulnerable groups
Lack of integration between dental and other health, social, education or community services
Services not commissioned based on oral health needs assessments
Workforce not trained to meet the needs of specific vulnerable groups
Services fail to meet the needs of vulnerable groups
Policies fail to address the social determinants of health.

Discussion

The purpose of this rapid review was to synthesise and describe the barriers to oral healthcare for vulnerable groups from the current international literature to provide a better understanding on which to inform commissioning and the provision of services. To our knowledge, this is the first comprehensive review aimed at synthesising barriers experienced by several vulnerable groups from different countries. The existing reviews on barriers to oral healthcare for people from vulnerable groups focus only on specific vulnerable categories.⁶⁵^,¹⁰⁹^,¹¹⁶

People from vulnerable groups continue to face a high burden of dental disease and difficulties accessing oral healthcare. There were common barriers experienced by almost all vulnerable populations, in addition to barriers specific to the characteristics of each group.¹⁶⁶ It is also important to appreciate that some individuals experience accumulative challenges as they belong to more than one vulnerable group; for example, an unemployed individual with physical disabilities living in a rural area who is from a minority ethnic group. Thus efforts to facilitate access must recognise and address the complex nature of the barriers faced.

This review identified the financing of dental services to be an issue at an individual level, with people unable to afford care and at organisational and policy levels. Indeed, the solutions suggested within the literature included the need for more public funding for dental services and/or ways to provide dental services for vulnerable groups more efficiently, such as through better use of skill mix or through the involvement of students. However, funding was not the only issue raised with a lack of integration of dental services with other health, social and community services cited as another recurrent barrier. Other recent reviews and reports¹⁶⁶^,¹⁶⁷^,¹⁶⁸^,¹⁶⁹^, have shown that globally there is a lack of coordination between dentistry and other services.

A strength of this review was the comprehensive reproducible search strategy and data extraction by two reviewers, as well as the rapid review approach. This enabled a relatively quick, yet in-depth, synthesis of the current evidence on barriers to oral healthcare for vulnerable groups to inform service providers, policy discussions and commissioning decisions.

There are, however, a number of limitations as a result of the methodological approach taken to ensure rapidity and due to the focused nature of the literature reviewed. The rapid review covered a ten-year period only, included only studies reported in English and only one database was searched. While this approach may be sufficient to capture most of the contemporary literature for these vulnerable groups, some relevant literature will have been omitted. Additionally, the lack of consensus of a definition of vulnerability means that certain individuals or groups may have been excluded. The included literature used a variety of different terms, for example learning disabilities, learning difficulties, mental disabilities and patients with special needs. The variety of terms used reflects differences internationally and changes in terminology over time. Some studies focused on specific conditions like autism or epilepsy, while others grouped conditions together or focused on groups of people or patients. Within groups, a range of severities of conditions means the identified barriers may apply to a lesser or greater extent. Also, some people have a combination of disabilities which make accessing care more complex and disabilities are commonly compounded by low socioeconomic status.⁷⁴ In this review, the literature for specific groups has been combined although different definitions and severities may exist. There are also differences between countries in attitudes towards vulnerable groups and in the legislation about the rights of people with disabilities and how this legislation is enforced. Similarly, there are differences in how dental services are organised and funded, which make some barriers specific to certain settings. The barriers identified in this review may be barriers perceived by the public, patients or dental professionals rather than actual barriers. The potential solutions stated are those suggested by the authors and have not been evaluated in terms of their clinical and cost-effectiveness.

Conclusions

Barriers to dental care for vulnerable groups have been identified at individual, organisational and policy levels, with significant commonalities between these groups. Numerous solutions to overcome these barriers have been identified, although there is little evidence to confirm the effectiveness or cost-effectiveness of these solutions.

Appendix 1 Countries of origin for included articles

Full size table

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University of Sheffield, School of Clinical Dentistry, Sheffield, UK
Sarab El-Yousfi & Zoe Marshman
Health Improvement Directorate, Health Intelligence. Public Health England, 5th Floor North, Wellington House,133-155 Waterloo Road, London, UK
Kate Jones & Sandra White

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Sarab El-Yousfi
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Kate Jones
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Sandra White
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El-Yousfi, S., Jones, K., White, S. et al. A rapid review of barriers to oral healthcare for vulnerable people. Br Dent J 227, 143–151 (2019). https://doi.org/10.1038/s41415-019-0529-7

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Published: 26 July 2019
Issue Date: July 2019
DOI: https://doi.org/10.1038/s41415-019-0529-7

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A rapid review of barriers to oral healthcare for vulnerable people

Abstract

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Key points

Introduction

Method

Results

Summary of the main common barriers

Individual-level barriers common across vulnerable groups

Organisational-level barriers common across vulnerable groups

Policy-level barriers common across vulnerable groups

Specific barriers identified for vulnerable groups

Summary of the main solutions

Box 1 Summary of the main common barriers

Discussion

Conclusions

References

Author information

Authors and Affiliations

Corresponding author

Electronic supplementary material

Supplementary Information 1 Ovid MEDLINE search strategy (PDF 322KB)

Supplementary Information 2 Barriers for each vulnerable group (PDF 747KB)

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About this article

Cite this article

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Prevention of oral diseases for the older person (Part 1)

Barriers to oral care: a cross-sectional analysis of the Canadian longitudinal study on aging (CLSA)

Bilingual dentistry - Improving access to dentistry for migrant populations

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Abstract

Similar content being viewed by others

Key points

Introduction

Method

Results

Summary of the main common barriers

Individual-level barriers common across vulnerable groups

Organisational-level barriers common across vulnerable groups

Policy-level barriers common across vulnerable groups

Specific barriers identified for vulnerable groups

Summary of the main solutions

Discussion

Conclusions

References

Author information

Authors and Affiliations

Corresponding author

Electronic supplementary material

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About this article

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