The Plymouth Foodbank (PF) is a community project established in October 2008 by the Plymouth Methodist Mission Circuit. It is located at the premises of the Crown Centre in Stonehouse; part of the political ward of St Peter's and the Waterfront in Plymouth. The PF works to fight poverty in the local community, primarily by providing free food to single people and families in financial crisis; with no money or means of getting food for themselves or their family. In addition, it also provides a listening ear and a signposting service. The clients using the services provided by the PF are mainly those with delays in receiving benefits (41%) and those with low income (16%).1 The organisation is also mainly used by those living in the St Peter's and the Waterfront political ward (33%). However, the organisation is not area sensitive and occasionally receives clients from other areas surrounding Plymouth.
The PF model is simple and involves collecting tinned and dried food from within the community e.g. from schools, churches, workplaces and by collections outside supermarkets. The food is then packaged into food parcels and stored at the organisations premises in Stonehouse. The organisation currently works with eighty nine different referral agencies in the city that assess clients who are in short-term financial crisis and are entitled to a PF voucher. The clients of these referral agencies are then able to exchange the voucher at the Crown Centre for a mixture of enough tinned and dried food to last them three days. However, the PF only provides a maximum of three vouchers a year to those in times of extreme crisis and it maintains that it is not a free supermarket.
Recent data indicates that more than 10,000 children in Plymouth live in homes that experience income poverty.2 In addition, more than 70,000 people in Plymouth live in areas of high deprivation.3 More significantly, the PF, which is located in the political ward of St Peter's and the Waterfront has the worst multiple deprivation score in Plymouth, and is in the worst 5% of wards nationally.4 Poor housing is also a problem in the ward, where only 22% of houses are owner occupied and there is the highest number of social housing in Plymouth.4 There are also a high number of people in the ward with low literacy skills compared with Plymouth as a whole.4 Furthermore, the ward has one of the highest unemployment rates in Plymouth, a city where 7.6% of the population was unemployed between October 2009 and September 2010.5 These figures clearly indicate that there are a number of social and economic issues affecting Plymouth and in particular the St Peter's and the waterfront political ward. Therefore it is suspected that in this area of high deprivation there will be poor general health and subsequently poor oral health.
This report aims to investigate the oral health issues faced by people using the services provided by the PF, such as those factors which influence oral health, including poverty, diet, education and access to dental care. In order to gain an insight into the organisation and its target population an interview with the manager of the organisation was conducted. This report will explore ways in which the oral health issues facing the target population can be addressed, making any recommendations on ways to improve the current services offered by the organisation.
Discussion
According to recent data, measures of oral health such as the number of drilled/missing/filled teeth (DMFT) have shown a marked decrease in recent year's indicating a considerably improvement in oral health in the UK.6 However, for the target population using the PF, the factors which play a crucial role in oral health are poor in comparison to the UK as a whole.
A balanced diet is a key factor in maintaining good general health. A poor diet has been linked to a lower life expectancy and diseases such as cardiovascular disease.7, 8 More significantly, a balanced diet is also a major factor influencing oral health. Diets that are low in fruit and vegetables or high in fats and sugar have been liked with a higher incidence of oral cancer.9
There are a number of barriers affecting access to a balanced diet, least of all the funds available to purchase food and the skills required to prepare the food. The food we consume consists mainly of protein, carbohydrates and fats; however not all food actually provides the necessary nutrients required for an individual's day to day need. The foods standards agency (FSA), a government organisation, has proposed the 'eatwell plate'. This recommends that a balance diet should incorporate one third fruit and vegetables, and one third carbohydrates - which can come from a variety of sources such as pasta and pulses. The final third should be split between protein, dairy foods and a small portion of foods containing high salt and sugar.10
The most prevalent oral health disease, caries, otherwise known as tooth decay, is defined as the progressive demineralisation of the hard tissues of the teeth by bacterial acid.11 Significantly, the aetiology of caries involves four major factors: bacteria, a susceptible tooth surface, diet and time.12 The specific constituent in the diet that leads to an increased incidence of caries is sugars and those classed as fermentable carbohydrates such as sucrose. It is therefore advised that the amount and frequency of sugars should be carefully controlled in order to prevent caries.
The target population of the PF are people who are in extreme financial crisis. This means that their major concern is not having the means to afford food, let alone food that would provide them with a nutritious and balanced diet. As mentioned by the manager of the PF, the people who use the services provided by the organisation tend to live on fast food which is high in sugar and salt content. Therefore it does not provide them with a balanced diet and increases their incidence of caries. Furthermore, the manager of the PF mentioned that another problem facing the target population is that they do not have the knowledge or the necessary cooking facilities in order to cook a balanced meal.
Although the PF try to provide the target population with a balanced diet, the food provided is dried and tinned produce which does not contain all the required nutrients as recommended by national guidelines.13 The organisation is limited insofar as they cannot provide fresh produce due to the higher costs involved in purchasing fresh foods as well as problems with its storage. In order to improve the diet and therefore both the oral and general health of the target population the PF offers cookery classes for individuals interested in learning how to prepare a balanced meal. Alongside these cookery classes it would be beneficial to give out diet sheets to understand what they usually consume and then analysed this with them in order to point out alternatives that will allow them to meet their nutritional requirements.
As mentioned previously, poverty is also a major factor influencing oral and general health. A number of studies have shown that poverty is related to a decline in oral health.14 The adult dental health survey supports this by stating that the DMFT scores are higher in those that come from low socioeconomic groups. In addition, this study indicates that those who work in professional jobs are more likely to have better oral health.6 The target population of the PF are those that are living in the two most deprived wards in Plymouth, St Peter's and the Waterfront and Devonport. Therefore it is expected that this group will have a higher incidence of caries compared with the overall population of Plymouth, as those people who are classified as living in low socioeconomic have a higher incidence of caries.15
Poverty not only affects the target population's financial ability to provide themselves with food, it also affects their means to purchase essential dental products such as toothbrushes and toothpaste. These are some of the things that would otherwise be considered normal for the average member of the public but are low on the list of priorities of the target population. The PF does currently stock basic dental supplies such as toothbrushes, which have been provided by the Peninsula dental school (PDS). However, after speaking to the manager of the PF it is clear that a regular supply of oral hygiene products for the target population would be very beneficial and very welcome.
Education is also essential for understanding the importance of oral health and the ways in which it can be maintained. Oral hygiene instruction (OHI) is crucial in improving the oral health of the target population; however, there is currently no OHI available to them. Therefore along with diet analysis mentioned previously, it would also be valuable for dental students from the PDS and local dental professionals to provide OHI classes which incorporate simple instructions such as brushing effectively using the modified bass technique and the method for using dental floss.
As previously mentioned, the target population fall into the category of those that are at high risk of getting caries and therefore it would also be beneficial to increase fluoride. Fluoride is invaluable in preventing the progression of caries and in the target population this would most probably be given topically.16 Oral hygiene in the target population could also be accessed by using a number of plaque indices such as the Silness-Löe or O'Leary's Plaque Index. In these processes, a disclosing agent, either a tablet or liquid, is used to identify areas of plaque on the surface of teeth. These areas appear coloured and can be used to identify areas that are being missed while brushing. This is a relatively quick and simple step that could be done almost anywhere.
Access to dental care is also a significant factor determining oral health. Visiting a dental practitioner on a regular basis as mentioned in national guidelines is essential in preventing oral disease such as dental caries. From interviewing the manager of the PF as well as volunteers it is clear that there is a major problem in accessing dental care in Plymouth and more significantly in the St Peter's and Waterfront ward where the PF is located. Although the organisation is aware of this and promotes the Devonport dental education facility it is important to mention that there is a considerably long waiting list for new patients. The local primary care trust, NHS Plymouth, however state that they are in the process of providing better access to dental care which will allow for an additional 10-11,000 patients to seen by an NHS dentist. 17
Summary, Conclusions and Recommendations
This report aimed to investigate the oral health issues faced by people using the services provided by the PF. From the visit to the PF it is evident that a number of factors which directly affect the oral and general health of the target population are at a significantly low level. It is also evident that these factors are disproportionately higher in the target population than that of the overall population of Plymouth. Additionally these factors make the target population more susceptible to oral health problems such as caries, which are preventable. By improving these factors it is possible to not only improve the oral health of the target population but also their general health and quality of life.
The first recommendation for improving the oral health of the target population is to educate them about what a balanced diet should consist of when they come to exchange their voucher for a food parcel. This could be achieved by explaining the 'eatwell plate' and analysing their usual diet and recommending healthier alternatives. Another recommendation would be for the PF to collect dental supplies such as toothbrushes, in the same way as they collect food provisions from the community. These could then be included in the food parcels.
OHI is a major factor which can also be improved by introducing classes that are given by local dental students and dental practitioners. These classes can concentrate on simple but effective skills such as tooth brushing and flossing. Finally access to dental care is a major problem for the target population and this could be improved primarily by actively promoting all the oral health services available to the target population when they initially visit the PF.
