How to improve care for stigmatized patients

2016 10 27 16 52 51 163 Male Dentist Female Patient 400

Patients with a history of addiction and mental illness sometimes experience being stigmatized by dental practitioners and staff, which can include being labeled, stereotyped, and discriminated against. A new study explored this issue and offered suggestions for improving dental care for this population.

Researchers conducted interviews with individuals with a history of concurrent substance addiction and mental health disorders to learn more about their experience of stigma when receiving medical and dental care. The study participants reported that they felt stigmatized when they were negatively stereotyped as unworthy, labeled as different, excluded from decisions about care, discriminated against, treated unfairly, and felt powerless during dental care interactions.

"Mental illness and addiction have negative implications for systemic and oral health, and when associated with stigma, they further impact access to care," the study authors wrote (PLOS One, May 22, 2017). "We suggest to continue to build on social awareness of health issues among current and future healthcare professionals to help improve the experiences for this marginalized population who already face numerous social, financial, and other barriers in life."

The researchers shared equally in the work. They were Mario Brondani, PhD, DMD, MPH, an associate professor and the director of dental public health, and Leeann Donnelly, PhD, an assistant professor, both at the University of British Columbia in Vancouver, as well as Rana Alan, DMD, of the Henry M. Goldman School of Dental Medicine in Boston.

Going straight to the source

According to one definition, stigma is a deeply discrediting attribute. Various people are stigmatized because of the way they look, behave, or present themselves to society, the study authors noted. Healthcare providers sometimes treat people with comorbidities, such as addiction and mental illness, this way, previous research has shown.

“Mental illness and addiction have negative implications for systemic and oral health, and when associated with stigma, they further impact access to care.”
— Mario Brondani, PhD, DMD, MPH; Rana Alan, DMD; and Leeann Donnelly, PhD

With mental illness being common among those with a history of addiction, the presence of stigma may cause this population to delay or avoid receiving dental care. This, in turn, can worsen oral diseases, including dental decay and abscesses, that substance users often experience, the authors wrote.

However, there is little research on the stigma faced by individuals with a history of addiction and mental illness when accessing dental care. The researchers conducted the current qualitative study to learn more about how such attitudes and behavior from healthcare providers in general and dental professionals in particular are experienced by this population.

They recorded semistructured interviews with 25 individuals between the ages of 23 and 67 years who were residents of two treatment centers in Vancouver for those with severe and complex concurrent substance addiction and mental health disorders. The participants were required to have visited a dental office after being diagnosed with a mental illness and to be dependent on at least one substance. They all received disability insurance that provides funds for basic dental care.

Participants completed a brief demographic questionnaire and underwent an interview conducted by the same researcher. This consisted of open-ended questions based on a model of stigma that acknowledges the influence of power, society, and its structural organization in encouraging or hindering the development of stigma.

The study participants were asked some of the following questions:

  • When was the last time you saw a dentist?
  • What happened during the visit?
  • How do you think healthcare providers in general and dental professionals in particular think/feel about you?
  • How do you think dental professionals listen to you and address your complaints? Why is that?
  • Is/was it difficult for you to book a dental appointment?
  • Do you think your needs with regard to dental care are met?

The subjects self-reported that they had been diagnosed with mental health conditions, including depression, anxiety, mood disorders, obsessive-compulsive disorder, schizophrenia, and post-traumatic stress disorder. They used various substances, including alcohol, heroin, crack, cocaine, and methamphetamine.

The interview results indicated that they experienced stigma in healthcare and dental settings both directly and indirectly. They felt that health professionals, including dentists, labeled them negatively, even though they might not say so.

The majority of study participants also indicated that they felt stereotyped by health professionals, including dentists, whom they felt were ignorant of issues related to substance use and mental illness. Some participants reported beliefs that health providers considered them inferior, unworthy, unwilling to improve their oral health, untrustworthy regarding pain medication usage, dangerous, or aggressive.

Some said that dentists appeared to blame them for their oral health status, which made them feel misunderstood and not cared for. This felt unfair to some of them since they said they had never been taught that their life conditions could negatively affect their oral health.

Some study participants felt that dentists avoided or minimized interactions with them during dental appointments, evidenced by behaviors such as avoiding eye contact or rushing appointments after being informed of or guessing about their mental illness or substance use.

Discrimination that appeared to take the form of hostility from the dental team, receipt of substandard care, refusal of services, inattentiveness, neglect through lack of proper communication, or unfair pain management during and after procedures also was reported.

To avoid some of the negative treatment they perceived and powerlessness they felt, some study participants said they covered up their conditions as much as possible.

"Our findings indicated that individuals with substance addiction and mental illness experienced overt or subtle stigmatization in dental settings similarly to other healthcare settings and other groups (e.g., HIV positive, obese, prisoners, and prostitutes)," the study authors wrote.

From the participants' perspectives, the lack of understanding about their life conditions was the origin of stigma, they noted. On the other hand, the participants reported positive experiences when dentists showed respect and compassion through effective communication and behaviors, such as making eye contact, speaking in a pleasant voice, taking time to explain the procedure, trying to manage their pain, and not looking down on or talking down to them.

The authors offered the following advice for providing dental care to this population:

  • Avoid victim-blaming and "take into account a patient's life situation and environmental factors, such as low level of knowledge or inability to access adequate resources, without stereotyping them."
  • "To avoid misunderstandings, patients should always be well-informed about prognosis and treatment possibilities and encouraged to take a more proactive role in the decision-making process."
  • "To help patients cope with their decreased sense of power, emphasis needs to be placed on communication, empathy, and rapport building skills."

Results may not be generalizable

The authors acknowledged that the generalizability of this study may be limited because of its relatively small sample size and that the characteristics of the participants may not be typical of the population with addiction and mental illness. Some study subjects also had other stigmatizing characteristics, such as being poor or of First Nations descent. Additionally, participants may not have distinguished between dental and other medical care in recalling stigmatization, and the model of stigma used may have offered a limited and negative view of stigma.

Other limiting factors included that dental practitioners were not included in this study and that personal biases could have been introduced in coding the participants' responses from interview transcripts.

The authors called for more research on developing strategies for reducing stigma and increasing quality of care for those who feel stigmatized.

"Further training on trauma informed care and culturally sensitive approaches are needed so that healthcare providers can appropriately work with stigmatized groups," they concluded.

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