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How does the dental benefits act encourage Australian families to seek and utilise oral health services?

  • Peivand Bastani ,

    Roles Conceptualization, Methodology, Writing – review & editing

    p.bastani@uq.edu.au

    Affiliation School of Dentistry, The University of Queensland, Brisbane, Queensland, Australia

  • Reyhane Izadi,

    Roles Data curation, Formal analysis, Software

    Affiliation School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

  • Nithin Manchery,

    Roles Project administration, Writing – original draft

    Affiliation School of Dentistry, The University of Queensland, Brisbane, Queensland, Australia

  • Diep Ha,

    Roles Formal analysis, Writing – original draft

    Affiliation School of Dentistry, The University of Queensland, Brisbane, Queensland, Australia

  • Hanny Calache,

    Roles Validation, Writing – review & editing

    Affiliation La Trobe Rural Health School, Australian Centre for Integration of Oral Health (ACIOH), La Trobe University, Melbourne, Australia

  • Ajesh George,

    Roles Conceptualization, Writing – review & editing

    Affiliations Australian Centre for Integration of Oral Health (ACIOH), School of Nursing and Midwifery, Western Sydney University, Penrith, Australia, Ingham Institute Applied Medical Research, Liverpool, Australia, School of Dentistry, The University of Sydney, Camperdown, Australia

  • Loc Do

    Roles Conceptualization, Supervision

    Affiliation School of Dentistry, The University of Queensland, Brisbane, Queensland, Australia

Abstract

Background

This study aimed to analyse the content of the Dental Benefits Act 2008 as a foundation for the Child Dental Benefits Schedule (CDBS) to determine how the Act encourages Australian families to seek and utilise oral health services.

Methods

This was a qualitative narrative document analysis conducted in 2022. Data was collected by searching formal websites for retrieving documents that reported the Australian Dental Benefits Act. The eligibility of the retrieved documents was assessed based on authenticity, credibility, representativeness, and meaningfulness of the data. A seven-steps procedure was applied for framework analysis.

Results

The content of the Dental Benefits Act 2008 provides directions on the three categories of operational, collective, and constitutional rules. Operational rules at the level of oral health providers and the population, as the service end users, can be demonstrated as rules in use in a mutual interaction with the collective and constitutional rules. The consequence of governing the rules at the community level can easily define how the oral health services are provided and utilised. The response is sent to the government level for better regulation of oral health service delivery and utilisation. Then, with interaction and advocacy with the diverse range of stakeholders and interdisciplinary partnerships, with community groups, non-government sectors and councils, the rules can be transformed, adopted, monitored, and enforced. Another mechanism of response has occurred at the providers’ and users’ level and to the operational rules to community groups and stakeholders via advertising and promoting the utilisation and provision of oral health services.

Conclusion

This study integrates the perspective of politicians with those of policy makers to reconsider the role and significance of the rules based on the triple collaborations among oral health users and oral service providers, the community, and the stakeholders as well as the government. A comprehensive attention is still needed in future revisions of the Dental Benefits Act 2008 according to the contextual factors, socioeconomic and geographical attributes of the population for better implementation of de facto rules and more effective outcomes of the interventions. It is recommended that further research be undertaken utilising a mix-method approach for a holistic view prior to further revisions of the Act or proposal of probable upcoming schemes.

Background

Oral health is integral to overall health and well-being of the population. This includes physical, psychological, emotional, and social domains [1]. Due to the multidimensional impacts of oral diseases, which include chewing problems, nutritional deficiencies and weight loss, irritability, insomnia, low self-esteem, and decline in social confidence and performance [2], oral health is considered, by World Health Organization (WHO), to be an essential part of general health interventions and practices [3]. To achieve this goal, global policymakers have tried to develop strategies to increase the population`s access to dental services along with improving the population’s oral health literacy, behaviours and service utilisation based on their contextual conditions, infrastructures, and facilities [4]. For instance, the National Institute for Health and Care Excellence (NICE) released policies and interventions for the improvement of the population`s oral health. These strategies are included in local health and wellbeing policies, public service environment and workforce policies, nursery services and school policies, and policies identifying high-risk groups for poor oral health [5].

In Australia, the provision of oral health services is either via a fee for services mechanism that operates within the private sector or via the provision of oral health services through State and Territory Government public sector for eligible population groups, which includes children and those with low socioeconomic status. Although there is a policy shift toward preventive services and early intervention programs among children and teenagers, two federal dental programs based on national laws and legislations were implemented over the period 2007 to 2013. These were the Chronic Disease Dental Scheme (CDDS) from 2007 to 2012 and the Medicare Teen Dental Plan (MTDP) during 2008 to 2013. The evidence related to the implementation of these programs indicated that these programs were not effective and had low utilisation rates particularly in rural and remote areas [6]. For instance, the evidence around the utilisation of MTDP in New South Wales (NSW) during 2008–2010 revealed concerns related to the program, which include lack of uptake, equity of vouchers’ uptake, availability, and willingness of the providers, particularly among rural and regional areas, to accept vouchers and insufficient support for providing follow-up care in the private sector [7]. These concerns may have contributed to the reasons for closure of the MTDP program by the Australian Federal government at the end of 2013. Following the trend and history of the national public programs, the Child Dental Benefits Schedule (CDBS) was implemented in 2014 to provide clinical dental treatments to eligible 2–17 years-old children and teenagers up to a payment limit of $1000.00 over two consecutive calendar years [8]. Since 2022, the eligibility has been increased to children 0–17 years with a payment limit of $1026.00 over 2 consecutive calendar years. Although a wider range of dental treatment services was included in the CDBS compared with the MTDP, low utilisation rate (23%) still exists [9]. Recent evidence by Stormon et al. (2022) indicates an increase of only 8% in access to dental services among low-income households through the CDBS [8].

Given the challenges for increasing the utilisation of the CDBS it is important to have a big picture of the acts, laws and legislations tabled and released by the parliament as the root and background of such schemes. Reviewing this information is important before policy makers make a conclusion based on the evaluation of such schemes and explore other avenues to redesign new interventions or continue with existing schemes, The Dental Benefits Act 2008 (the Act) which commenced in June 2008 is one of the critical legislative frameworks for the provision of dental benefits in Australia. The Act has had four reviews over the previous decade. The first review which was tabled in parliament in 2010, mainly focused on the attainment of the purpose and the administration of the Act related to the MTDP (10). The second review in 2012, concentrated on the operations and administration of the Act related to the MTDP. The third review led to the closure of the MTDP and the establishment of the CDBS and finally, the fourth review in 2019, considered the operation and administration of the Act, in relation to the CDBS [10].

Being successful with the purpose of implementing such an Act, via the stated schemes is not only related to the clarity, power, coverage, and legal and administrative aspects of establishing the rules by the government which are labelled as constitutional rules but also depends on both collective rules and operational rules. In other words, constitutional rules, as defined by the government, can affect the formal and informal aspects of collective rules. Constitutional rules are those based on approved formative constitutions related to fundamental principles of the government`s authority which define the interpretation and application of the powers, rights, and freedoms. Collective rules are set by the community groups and can affect the operational rules via their impacts on the demand and supply side of the oral health market including community groups, religious groups, women or other vulnerable parties on the demand side and the professional groups (oral healthcare providers), government and local councils on the supply side. The operational rule is where individuals (users and providers) make choices and where rules-in- form (de jure rules) transform into rules-in-use (de facto rules) [11]. For more clarity, de jure rules (rules-in-form) describe those practices that are legally recognised, regardless of whether the practice exists in reality while de facto rules (rules-in-use) describe those practices that exist in reality, even though they are not officially recognised by laws. Many determinant factors can be considered from the users’ perspective while the market forces defined by demand and supply rules can also be influential in day-to-day decisions of the population to utilise the oral health services. These are all considered as operational rules that can be affected directly by collective rules or both directly and indirectly by constitutional rules. Context including this rule in use, socioeconomic and geographic attributes, can affect the whole collaborations among these triple rules. Fig 1 illustrates this conceptual framework.

In order to make an understandable and recognisable language between politicians, policy makers and healthcare providers in the area of oral health, we plan to review the content of the Act and its related reviews, considering the government not only as a singular entity and steward of the community’s health but also as the enforcer or the body that implements the rules directed by the acts and at the same time organised by authorities and informal groups and stakeholders [11]. Such a framework can present a rational combination among the directions of the acts set by politicians and the governors’ rules in oral health. So, this study aimed to analyse the content of the Dental Benefits Act 2008 to determine how this Act encourages Australian families to seek and utilise oral health services.

Method

This qualitative narrative document analysis, was conducted in 2022, using a framework analysis approach. The full content of the Australian Dental Benefits Act 2008 and the related reviews were considered as the qualitative data. As mentioned by two of the qualitative experts Gupta (2015) and Krippendorf (2012), official governmental documents, guidelines and directives, programs, policies and periodic reports, and the content of laws and legislations can be analysed for their contents as a rich qualitative source of data [12, 13].

Data collection

Data was collected by searching the formal websites for documents related to the Australian Dental Benefits Act 2008. The whole content of the Act as well as the four versions of its revision were retrieved as the public free documents. The eligibility of the retrieved documents then was investigated and approved according to the suggested criteria by Scott (2014) including authenticity, credibility, representativeness, and meaningfulness of the data [14].

Data analysis

After retrieving the data and inclusion of the documents according to Scott criteria (2014), we have used the procedure suggested by Gale et al. (2013) for framework analysis including the following seven-steps [15]:

  • Transcription: This first step was not actually done due to the existence of a portal document format (pdf) of the Acts files. So, the content of the files was saved in a word format with large margins and sufficient line spacing for later coding and note taking which occurred in the following steps.
  • Familiarisation: To be familiar with the content of the Acts, all the files were read several times line by line. All the impressions or important issues were noted in the margins of the pages.
  • Coding: at this point, after familiarisation with the whole texts, the parts related to the research question were highlighted and a paraphrase or label was selected which can describe well the interpretation of the text. These labels demonstrated the initial codes. This was an open coding inductive approach with the aim of summarising the whole data towards the main concept.
  • Developing a working analytical framework: In this step the initial codes extracted from the content of the Act by one of the researchers (RI) was reviewed by the team and the code labels were discussed, compared, and agreed to by the team. Then the initial codes were categorised to make the final codes apply to a tree diagram to develop an initial analytical framework.
  • Applying the analytical framework: MAX QDA version 10 was used in this step as a Computer Assisted Qualitative Data Analysis Software to determine the relationships among the initial codes, final codes, and upper-level categories. These categories first create the sub-themes and synthesised the sub-themes to achieve the main themes.
  • Charting data into the framework matrix: To integrate the inductive open coding approach with a deductive conceptual framework which best fits the emerging concepts, the triangle of rules proposed by Abimbola (2020) was applied [11] at this stage. Then the data was charted into a table based on the developed framework (Fig 1).
  • Interpreting the data: In this last step, the developed framework including the main themes and related sub-themes were described and interpreted in accordance with prior concepts and new ones emerging from the data.

Data robustness and trustworthiness

Four criteria suggested by Lincoln and Guba (2017) were applied to ensure data analysis robustness and trustworthiness including credibility, transferability, dependability, and confirmability [16]. To achieve credibility, prolonged engagement with the data occurred through a familiarisation process. The coding process was initially done by RI and NM and finalised by PB through a consensus meeting. An external check was also done by a qualitative research expert outside of the research team to review the whole research process, which was followed by a debriefing session. Presenting a thick description of the findings was then implemented to achieve transferability. To ensure dependability, the whole research process was documented clearly in detail and with a logical and traceable manner. And finally, to get confirmability, the interpretation of the findings was described objectively and neutrally to show that all the findings were derived from the initial data. Furthermore, the reflexivity of the qualitative analysis was assured by the research team collaborating with the qualitative research experts (PB, AJ, HC).

Ethical considerations

Data was analysed by two of the authors (RI and PB) with no conflict of interest against the topic. Ethics clearance was not required.

Results

The content of Dental Benefits Act 2008 provides directions on all three categories of operational, collective, and constitutional rules. Tables 13 demonstrate the main themes and sub-themes identified from analysing the content of the Act in each category of the rules.

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Table 1. The main and sub-themes related to operational rules.

https://doi.org/10.1371/journal.pone.0277152.t001

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Table 2. The main and sub-themes related to collective rules.

https://doi.org/10.1371/journal.pone.0277152.t002

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Table 3. The main and sub-themes related to constitutional rules.

https://doi.org/10.1371/journal.pone.0277152.t003

Operational rules

Table 1 illustrates three main themes and ten related sub-themes in the category of operational rules. These main themes include consequences of the rules governing how dental services are used and provided, how they respond to the collective rules as the norm for the use and delivery of dental services, and how they respond to the regulations on service use and delivery.

According to the results, the content of the Dental Benefits Act 2008 can either respond to collective rules and norms for service use and delivery and at the same time make a response to regulation on service use and delivery (Table 1). In other words, the content of the Act summarises the advertising norms and other promotion strategies as a marketing mix for improving the utilisation of oral health services and promoting oral health behaviours among particular and vulnerable groups. This can be a defined mechanism of responding to collective rules and norms by the community to deliver/provide and utilise oral health services. At the same time, the Act summarises the concept of requirements for utilisation of dental services by eligible groups, rate of utilisation and provision of dental services based on the population strata, financial mechanism, and geographical access, as well as legal facilitators and barriers for service delivery, provision, and utilisation. This category of the rules also indicates the consequences of the rules governing how the service is used and provided. Two consequences of the rules can be considered from the content of the Act as sub-themes including general rates of use and delivery of services, as well as utilisation and service delivery rates based on specific strata/ geographical areas and public and private sectors.

Collective rules

Similarly, Table 2 demonstrates the main theme and sub-themes related to the category of collective rules. The main theme that emerged here was “forming the level of the constitution to the enforcement of collective rules”, which includes two sub-themes: ‘Transforming and adapting the rules from the constitutional level’ and ‘making the mechanism for monitoring and enforcement of collective rules. These two sub-themes make and form the level of the constitution to the enforcement of collective rules.

Constitutional rules.

And finally, Table 3 presents a related theme and two sub-themes in the category of constitutional rules. “Legitimising the role of collective level of governance” emerged as the main theme and includes the two sub-themes of “power reference and steward authority” and “rules and plans: creation, modification, enforcement, and external monitoring”. Power reference and steward authority by the Ministry of Health at the national level and authorisation of the State and Territory governments along with creation, modification, enforcement, and external monitoring of the rules and plans can legitimise the role at the collective level of governance to the constitutional rules at the politician’s macro level (Table 3). This process of creating, modification, enforcing and monitoring of the rules and plans can be implemented and organised by the direct and indirect feedback from the community and service users.

Considering the results of the present document analysis, politicians and policy makers at the macro and government level can affect all three constitutional, collective, and operational rules. People and families and oral health providers could then make change, monitor, and enforce formal and informal rules which can be in each of the three categories of operational, collective, and constitutional rules. These three categories of rules can then affect their actions, decisions, and relations (Fig 2).

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Fig 2. The framework of rules directed from Dental Benefits Act 2008.

https://doi.org/10.1371/journal.pone.0277152.g002

As is illustrated in Fig 2, the operational rules at the level of oral health providers, including dental specialists and the population as the end users of oral health services, can be demonstrated as rules in use in a mutual interaction with the collective and the constitutional rules. The consequence of governing the rules at the community level can easily define how the oral health services are really provided and utilised. It is clear that the response is sent to the government level for better regulation of dental service delivery and utilisation. This is then followed with an interaction and advocacy with a diverse range of stakeholders; collaboration across disciplines and capacity to establish, build, and sustain intersectoral and interdisciplinary partnerships with the community groups, non-government sectors, councils, and communities. In this way the rules can be transformed, adopted, monitored, and enforced. Another mechanism of response is occurring from the providers’ and users’ level and the operational rules to community groups and stakeholders via advertising and promoting the utilisation and provision of oral health services.

Discussion

This study is conducted to determine how the content of the Dental Benefits Act 2008 can help increase the utilisation of oral health services via two schemes of MTDP and CDBS that the Act mainly focused on during that time. The significance of such an analysis becomes more notifiable and highlighted considering that according to the Australian Institute for Health and Welfare, some groups of the population are at greater risk of poorer oral health, included among them are those with lower socioeconomic status, Australian Aboriginal and Torres Strait Islander people, those who live in regional and remote areas and those who need additional or special health care needs [17].

To achieve the optimal consequences of dental services provision and utilisation, the Act pays attention to a dual mechanism of advertising norms and promoting strategies as a marketing mix for dental services utilisation and at the same time defining the target group via eligibility requirement setting, rates of dental services utilisation and provision based on geographical area / specific strata, financial mechanisms, and the types of bills. Although it seems that the dual mechanism can be considered as the response to collective rules and regulatory and constitutional rules towards the community and stakeholders and the government, it still needs to concentrate on the other significant factors that could help increase the utilisation of dental services among vulnerable groups. The evidence from a retrospective utilisation rate of CDBS as one of the emphasised schemes by the Act also shows that the rate of utilisation during 2014 and 2015 was low and varied among Australian states and territories (18). In contrast with the low rate of utilisation it is important to mention that according to Putri (2020), preventive services were recognised as the most utilised services among the eligible population during 2014–2015 [18]. Such evidence can highlight the gap that although the Act includes the concept of advertisement and promotion as the marketing mix for the schemes, attention was not paid to the concept of social marketing as well in order to promote oral health behaviours. At the same time, in contrast with the inclusion of eligibility requirements for the target groups in the Act, according to the findings of Orr et al. (2021) some lower levels of preventive services utilisation are obvious among Aboriginal children as one of the most eligible and vulnerable groups [19].

The Act has considered two concepts of power reference and steward authority and creation, modification, enforcement, and external monitoring of the rules and plans for legitimising the role of collective level of governance. In this category the concepts of people’s communication channels and people`s feedback about the schemes is considered. The quantity and quality of the feedback could be diverse according to the results of Nguyen et al. (2020). Those mothers with lower socioeconomic status level, those who have experienced any kind of depression or with lower levels of mental health, and the mothers with a type of health behavioural problem like smoking or even poor oral health behaviours, had the lower tendency to claim the available benefits of CDBS for their children [6]. According to this, it would be important to find the mechanism for weighing the feedback or finding some more robust channels and real feedback on the utilisation of the services by the Australian families.

Another overlooked point that needs more attention in the potential revisions of the Act is to focus more on the coverage of the services highlighted in the Act. For instance, although the present results show that monitoring, transforming, adopting and enforcement of the rules is important to translate them into practice by the end users, evidence implies that some types of preventive services provisions by an alternative workforce are not supported by the fourth revision of the Act such as fluoride varnish items provided by dental assistants because there was not any defined mechanism for receiving and reviewing the changes and revisions via the Act [19]. Similarly, for those Indigenous population groups who use CDBS voucher, two concerns are mentioned. Firstly, the variety of service provision based on different locations that led to a poor coverage of just over 20% of the concession card holders and secondly the exclusion of many services like orthodontics from CDBS and the need for such services to be undertaken by the private sector [20]. So, as the main concentration of the Act and the CDBS is on preventive schemes, it would be more effective and valuable, in the next revisions of the Dental Benefit Act (2008), to include, according to the needs (and unmet needs) of the eligible population, in a package all the probable essential dental services for this population group. Also, from the coverage perspective, there should be a new policy dialogue to identify strategies for increasing the utilisation of the services particularly during and after COVID-19 era. According to Hopcraft and Farmer (2020), from a retrospective analysis of Medicare data on CDBS utilisation, a large decline was observed in the provision of preventive and diagnostic services during the pandemic in comparison with the utilisation of endodontic and oral surgery services [21].

This study attempted to integrate the perspective of politicians with those of policy makers to reconsider the role and significance of the rules based on the triple collaborations among oral health users and oral service providers, the community, and the stakeholders as well as the government. The Australian Dental Association is among one of main stakeholders which could influence in shaping the rules and service codes. This national voluntary professional organisation which has branches in all the States and Territories, could act as a bridge between the dentistry society particularly private practitioners and the community to help improve the provision of dental services according to the oral health and general health needs of the population.

This study was accompanied with some limitations as follows: the national document analysis of the Acts and legislations would have been enhanced if it were triangulated with an in-depth qualitative data collection (and analysis) from the perspective and experiences of service users and providers, as well as the inclusion of quantitative statistics for the utilisation rate of the schemes. Undertaking a mix-method study for a holistic view prior to the further revision of the Act or probable upcoming schemes are recommended.

Conclusion

Utilisation of the oral health services by the population is a strategy considered by the Australian health system as a way of achieving, as a final goal, optimum oral health for its population. For this purpose, coordination and integration of the laws and legislations at the Parliament and politician level with those applied policies, interventions, schemes and regulations by the government and policy makers is necessary. The Dental Benefit Act 2008, as a foundation for MTDB and CDBS, is the key Australian legislation which tries to consider all the operational, collective, and constitutional rules with a mutual relationship with the population as the end user of oral health services; the oral health providers; the community and stakeholders; and the government and oral health policymakers. However, a comprehensive attention is still needed in future revisions of the Act according to the contextual factors, socioeconomic and geographical attributes of the population for better implementation of de facto rules and more effective outcomes of the interventions. It is recommended that further research be undertaken utilising a mix-method approach for a holistic view prior to further revisions of the Act or proposal of probable upcoming schemes.

Acknowledgments

The authors would like to acknowledge and thank A/Prof Mohammad Amin Bahrami who was the external qualitative research expert that reviewed the whole research process, and participated in a debriefing session.

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