This theme focuses on the deficiencies that are present at the district level to enhance access to oral health care for these patients. The interview with the district health coordinator suggested that oral health strategies remain isolated from general health interventions, as indicated in the following quotation:
“We do not have a separate policy on oral health care for head and neck cancer patients. I have not seen one specifically for head and neck patients. But we got a specific policy in KZN as to decrease the filling to extraction ratio which at the moment is sitting at 1:20. By 2021/2022 we want to bring it down so that for every 10 extractions we do a filling”.
A similar response was obtained from the district coordinator on the availability of life-style induced health risk-related intervention programmes, highlighting therefore a gap in service delivery:
“We do not have any (risk factor intervention program) but we do encourage all our patients not to smoke and drink.” (oral health district coordinator).
Oral health care has a significant role in cancer patients as it dictates the overall well-being of the individual (Bueno et al., 2015). A study conducted in North Carolina on cancer patients reported that participants who had dental or oral problems were also those who experienced inferior emotional health, deficient physical functioning and poorer quality of life as compared to those who did not have any oral health-related issues (Ingram et al., 2005). A risk factor intervention program is important to address common risk factors for non-communicable diseases (in this case head and neck cancer) as part of health determinants (Molete, Daly and Hlungwani, 2013).
Oral health is vital for the overall well-being in cancer of the head and neck (Pateman et al., 2015). Thus, oral hygiene maintenance is of utmost importance in these patients (Samim et al., 2016). Toothbrushing, flossing and mouth rinse are vital and effective strategies to this population group as part of an appropriate oral health care regimen (Deng et al., 2015; Gupta et al., 2015). In general, the participants were knowledgeable about the importance of oral
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health with respect to their overall health and were practicing on at least one of these strategies.
One unique interviewee however, denied that oral health is vital for the overall well-being.
Hence, on-going oral health education about the importance of oral hygiene maintenance before, during and even after therapy and providing appropriate treatment are integral to improving oral health literacy and also quality of life (Plemons, Rankin and Benton, 2013;
McQuistan et al., 2015; Samim et al., 2016). This forms part of the dental professionals’ duty (Plemons, Rankin and Benton, 2013; Samim et al., 2016). This is however not possible in the presence of factors preventing access to oral health care as observed in this study. Barriers at both the individual and district levels have been noted.
Low income, living in a socially deprived area where there is no dental facility and long distance to dental clinics, as expressed by the participants, were among the most striking factors related to inaccessibility to dental care. This is consistent with the literature which reports that socially marginalised and disadvantaged groups have reduced access to health services (Petersen, 2009b). The overflow of patients in local clinics resulting in long waiting hours was also expressed as a barrier to use dental public services. All these factors can be attributed to a lack of coordinated and integrated oral health planning which, when present, can eliminate inaccessibility to oral health care (Thema and Singh, 2013). Previous studies also reported of similar barriers to accessing effective oral health services (Vargas and Arevalo, 2009; Molete, Yengopal and Moorman, 2014; Almado, Kruger and Tennant, 2015). The lack of referral by the oncology doctors to obtain dental care in this tertiary centre was another significant barrier identified. This deficiency might be attributed to the fact that doctors are unaware of the importance of dental assessment and oral health care in this population group (Lawrence, Aleid and McKechnie, 2013).
Guidelines issued by the National Institute for Clinical Excellence recommend that all patients about to start head and neck cancer therapy should be referred to dental professionals by their service providers to decrease the incidence of oral complications related to the multimodality oncology treatment (Lawrence, Aleid and McKechnie, 2013; Samim et al., 2016).
Another limitation identified is the lack of dissemination of information related to oral complications of chemotherapy to patients by other members of the MDT (Oncologists and nurses). Poor knowledge of oral health care on their part might be the likely reason. This observation is consistent with another study which also reported that nurses demonstrated weak oral health care knowledge of cancer patients (Pai and Ongole, 2015). Continuous inter-
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professional oral health care education that incorporates evidence-based strategies of oral health care should be prioritised for improved patient outcome (Pai and Ongole, 2015). In this way the knowledge can be spread from professionals to patients. Developing and following oral health care recommendations to provide comprehensive care to patients undergoing therapy for cancer is equally meaningful (Kav et al., 2008; Pai and Ongole, 2015).
Integrated planning is vital for oral health promotion activities (Thema and Singh, 2013), yet a substantial deficiency, as observed in this study, is the absence of a specific policy planning at the district level in the interest of these patients. Furthermore, the Common Risk Factor Approach is a means by which oral health promotion can be incorporated in general health so that risk factors which are similar for non communicable diseases (hence including head and neck cancer as well) can be addressed as part of health determinants (Molete, Daly and Hlungwani, 2013). This approach is supported by the South African Oral Health Promotion framework (Molete, Daly and Hlungwani, 2013). However, absence of a risk factor intervention program for promotion of oral health is another major gap that was identified in service delivery for this population group. Education on the consequences of tobacco smoking, alcohol consumption, areca nut chewing and other risk factors should be part of a properly structured oral health promotion programme in addition to routine toothbrushing and flossing methods. Education about life threatening consequences of lifestyle risk factors is important to decrease the severe financial burden on both patient and State (Abdo et al., 2007; Abreu, Kruger and Tennant, 2009; Joshi et al., 2014). Literature reports that educational campaigns can help to implement this type of approach (Nemoto et al., 2015). However, very often campaigns do not include the high-risk population who genuinely represent the originality of the problem being addressed (Nemoto et al., 2015). Thus the number of participants should be as big as possible and should target those at high risk for developing head and neck malignancy, especially those living in underdeveloped regions because they are the ones who have more exposure to tobacco, alcohol, carcinogenic viruses and other avoidable risk factors and also experience reduced access to education besides health services (Petersen, 2009b; Ford et al., 2013; Nemoto et al., 2015). Thus, holding campaigns at different periods during the year and planning home visits to the at-risk and socioeconomically marginalised, instead of them travelling to participate in such campaigns is one way through which this approach can be implemented (Nemoto et al., 2015). Inadequate human and financial resources were blamed for this shortfall in oral health promotion strategies. Adequate workforce is critical for delivery of high quality dental care since 80% of the South African population utilises public dental
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services (Bhayat and Chikte, 2017). The dentist to population ratio in SA was 1:8900 in 2015 according to the latest available data, while it is 1:2000 in developed countries (Bhayat and Chikte, 2017).
The support needs of the participants were largely met by their families. Moral and financial support were the most common forms of support that they received. Moral support is indispensable since it contributes to better handling of psychological and physical challenges to which head and neck cancer patients are confronted and results in improved well-being (O’Brien et al., 2017). Financial support in cancer is crucial as it is reported to be accompanied by severe financial strain (Zaidi, Ansari and Khan, 2012). Prayer was another form of support provided by the family. Prayer/spirituality is recurrently used in chronic illnesses and helps to cope better with undesirable situations (Mesquita et al., 2013; Jors et al., 2015). Many studies also reported that prayer is a powerful and effective approach to cope with cancer (Mesquita et al., 2013; Carvalho et al., 2014).
Limitations of the study
This study cannot be generalised. The study participants were drawn from a single site and the results cannot be extrapolated to other provinces and districts. However, this study provides valuable data on access to oral health care given that no study so far has explored the oral health needs of head and neck cancer patients in the province of KwaZulu-Natal. Future research in this population group across all the provinces of South Africa would be helpful so that national policies can be formulated to better meet the oral health needs of this population group.
Conclusion
The results indicate that support for oral health promotion is important for patients undergoing head and neck cancer therapy, but there are substantive gaps and barriers in accessing oral health care. There is an urgent need for oral health planning in the province to take into account the specific oral health needs of this vulnerable population.
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