INNOVATION IN ORAL HEALTH CARE - COHW-report presentation

Location of Field Practicum : Jan Swasthya Sahayog, Chhattisgarh

Guided By : Dr. Mariappan M. & Dr. Yogesh Jain

Field Practicum - Presentation

Community Oral Health Workers

(COHW)

For rural, un-served and under-served areas

http://ii.unipune.ac.in/idea/getIdeaProfile?idea_id=486








RATIONALE

Oral health status in India Today

Prevalence of dental caries is 40%-80%

(Very high in Northern states 85%-90%)

Periodontal conditions (disease of gingiva, periodontal ligaments and supporting bone) usually increase with age

These types of diseases cause teeth loosening and they consequently fall

Very common in rural areas

Oral cancer and precancerous conditions are 3%-10% (Highest in Orissa 7%)

Chhattisgarh, Madhya Pradesh & Orissa share a common culture of addiction to

GUDAKHU- a proven potential carcinogen

GUDAKHU

Ingredients:

1. Tobacco- 10%

2. Molasses- 35%

3. Lime- 7%

4. Red soil- 28%

5. Water- 20%

INDIA IS MARCHING AHEAD IN ORAL CANCERS

SITUATION ANALYSIS

Objectives

To assess the status of oral health and related KAP in the tribal communities of rural parts of Bilaspur district in Chhattisgarh

To assess shortcomings in government policy and plan, access, service provision

To analyse various oral health service and workforce models that were evolved around the world to bridge the gap in rural and urban oral healthcare in similar situation

To provide a practical intervention to solve the problem

SITUATION ANALYSIS

Key Findings

Source: JSS, Ganiyari

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Bacterial

Transmision

Importance of

fluoride

Effects of

excess fluorine

Importance of

oral hygiene

during

Pregnancy

Baby teeth

Development

Oral hygiene

Habits for kids

Use of baby

tooth brush

1st dental visit

of the baby

Teeth can be

saved by

treatment

SITUATION ANALYSIS

Key Findings

Population Total 25837

Male 13405

Female 13283

Sex ratio 990.89

Caste ST 70.36 %

SC 4.95 %

OBC 23.12 %

General 1.04 %

Other 0.51 %

Ration Cards APL 11.85 %

BPL 74.07 %

No Cards 14.09 %


11,

14%

16,

20% 42, 54%

9, 12%

Distribution of Phulwaris

Shivterai

Semariya

Bamhni

Achanakmar

590,

50%

579,

50%

Children in Phulwari

Male children

Female children

12, 1%

925, 80%

224, 19%

0, 0%

Caste-wise composition of phulwaris

SC

ST

OBC

Other

110, 14%

234,

31% 327,

43%

90, 12%

Children Below 3 years

Shivterai

Semariya

Bamhni

Achanakmar

0

10

20

30

40

50

60

No. of total

villages in

cluster

No. of villages

having

phulwari

54

35

14, 13%

93, 87%

Literacy status of 107 phulwari workers

Can read and write

Cannot read and write

CRECHES: FOR LESS THAN 3 YEARS CHILDREN - PHULWARI PROGRAM @ JSS


1. Agriculture - the main occupation of

people in this part of the country

2. Children are undernourished - direct

effect on their oral and general health

3. Lack fluorine is observed in some parts

of the country, whereas tribal belt like

Chhattisgarh and Madhya Pradesh

experiences very large amount of

fluorine content in water.

MAJORITY IN THIS REGION - THE VULNERABLE

(TRIBAL POPULATION)

DENTAL FLUOROSIS IN CHHATTISGARH

A study in Amatikra, raises the issue of Dental fluorosis that has been brought

to the notice of policy makers by Jan Swasthya Sahayog, providing health care services

in the tribal areas of Chhattisgarh.


SPECTRUM OF CANCERS SEEN (2011-2013)

0

50

100

150

200

250

300

350

400 353

146

74 62 49 45 27 23 21

Number of patients


CANCER - HEAD AND NECK (2011-2013)

0

20

40

60

80

100

120

140

Oral Others

129

17

Number of cancers


Differentiation of

oral cancers Numbers

Buccal 31

Cheek 18

Gingiva 24

Palate 12

Lip 9

Mandible 14

Oropharynx 1

Tonsil 20


ORAL CANCER LOCATION (2011-2013)

SURGICAL INTERVENTION (2011-2013)

Oral

Definitive 27

Palliative 6

Could not decide whether it was definitive

or palliative 2

Total surgeries done 35

Total patients 127


ORAL HEALTH WORKFORCE SHORTAGE

Sad reality in this part of India

• In more than 54 villages which are served by JSS,

there is not a single qualified oral health service

provider

• Patients largely depend on traditional healers, some

take painkillers from family doctors and pharmacists

for episodes of toothache

GETTING TREATED BY

UNTRAINED

TRADITIONAL HEALERS

झोलाछाप दाांत वाले

Continuing with compromised

oral health and pain in oral cavity Picture from Achanakmar,

Chhattisgarh – taken during Oral

Health Check-up camp

BILASPUR DISTRICT

RURAL - URBAN DIVIDE

Services are in contrast to need:

Oral healthcare service providers are mostly concentrated in the Bilaspur city and no services either by Public or by private exists in the rural and tribal areas of Bilaspur District

The only facility available is the New Horizon Dental College, which is private college and also far from the villages

Vulnerable population -Areas are cut off from the main areas where

services are available.

Un-served/ underserved

Services Inaccessible – Bamhani village

Travelling, food, loss in daily wages and

expenses on the treatment

Cannot think of repeated visits for continuation

of treatment and follow up

Financial Barrier

GOVERNMENT POLICY AND PLAN

1. National Oral Health Policy, 1996 (Only a paper work): Entirely missing in

terms of service provision as well as human resource planning for oral healthcare

2.NRHM:

Administrative Problems: Fewer facilities, irregular recruitment, temporary nature,

basic infrastructure is either missing or in broken condition

Human Resource Problems: Without much supervision, with very poor

remuneration


3. Central Government Health Scheme (CGHS) and Employees State

Insurance Corporation (ESIC) : Only limited coverage for few

4. Rashtriya Swasthya Bima Yojana (RSBY) : Covers many oral healthcare

procedures.

But,

Lack awareness about dental scheme

Lack of such oral healthcare facilities where RSBY card can be used

Even the dental college of this region does not have linkage with RSBY scheme


Rapid expansion of dental education system

Rural internship

Compulsory service-bond

10-30% concession of marks in post-graduate entrance examination to attract dental graduates in rural services

But, Centre as well as states still struggle to retain workforce

WHAT NEXT.....?

There is a need to explore other alternative methods

FOR TAKING ORAL HEALTHCARE TO THE UN-SERVED AND UNDER-

SERVED AREAS OF INDIA

INTERVENTION DESIGN

LEARNING FROM THE WORLD AROUND

Emerging Workforce Models around the world

1. Expanded Function Dental Auxiliary : Since 4 decades

2. Community Dental Health Coordinator Public health clinics, and private practices

in underserved areas (Focus on health promotion, oral health literacy, community field

experience )

3. Dental Health Aide Therapist – DHAT* (Alaska model)

4. Dental Therapist/Advanced Dental Therapist – DT/ADT (Minnesota model) :

Bachelor’s prepared (under supervision of a dentist) and Master’s prepared (without

requirement for onsite supervision) 5. Advanced Dental Hygiene Practitioner – ADHP*- Provide care in public health settings—schools, clinics, and long-term care facilities, etc.

WHICH WORKFORCE MODEL SHALL WE

ADOPT??

1. Oral health needs of the local community and region

2. Available infrastructure and Resources

Training Centre

Material Resources

Human Resources

Financial Resources

3. Cost involved

4. Availability of reimbursement

for services

5. Ability to evaluate impact

OBJECTIVE OF INTERVENTION

Objectives

A program for the community setting and evaluate it

Design and evaluate IEC material

Fill the vacuum in oral healthcare service delivery (in consultation with local stakeholders)

Document the process and evolve a model suitable for Indian context on a larger scale

INTERVENTION PLAN/ METHOD

Initiated The JSS - Community Oral Health Program (COHP), which was launched in two

phases simultaneously

1st phase : Initially: Using the existing infrastructure and already available human resource

begin with training of:

1. Teachers (Cluster Co-ordinators in JSS),

2. Senior Community Health Workers (SHW) and

3. Village Community Health Workers (VHW) in acquiring Oral Health knowledge and

skills in basic oral health and hygiene, prevention and promotion with the objective that

Community Health Workers would later on deliver the oral health related information

and education to the community, thereby creating awareness in the community about:

• oral health and hygiene

• oral disease prevention

• oral health promotion

2nd Phase : Establishing a Community Oral Health Clinic with the objective of meeting the

oral health treatment needs of the community

A BRIEF DESCRIPTION OF THE INTERVENTION

PHASE - 1 S.No. Activity Description Dates + Place Request of support

1 Training of

Teachers

(CC+ SHW)

1day

Training of :

9 Cluster Co-ordinators + 9 Senior Health Workers HOW TO

TRAIN - VHW and ORGANIZE future community programs

Mon-2nd September

@ JSS

1 day Seminar Hall

+

1night + 1 day

Accommodation + Food

for participating CC+SHW

TA+DA

2 Village oral

health Camp

29days

Training +

Screening +

IEC

Bamhani

5days

Training of VHWs + Fulwari workers Tues-3rd September +

Wed-4th September

Travel to Bamhani/

Accommodation

+

Helping Staff Screening of patients & IEC

(@KATAMI)

Thur-5th September +

Fri-6th September +

Sat-7th September

3days Reserve Sun-8th September to Tue-10th

September

Shivtarai

4days

Training of VHWs + Fulwari workers Wed-11thSeptember+

Thur-12th September

Travel to Shivtarai/

Accommodation

+


(@KARPIHA)

Fri-13th September+

Sat-14th September

3days Reserve Sun-15th September to Tue-

17thSeptember

Semariya

5days


Thur-19th September

Travel to Semariya/

Accommodation

+


(@BARAR)

Fri-20th September+

Sat-21st September

3days Reserve Sun-22ndSeptember to Tue-

24thSeptember

Achanakmar

5days


Thur-26th September

Travel to Achanakmar/

Accommodation

+

Helping Staff Screening of patients &

IEC)@ACHANAKMAR)

Fri-27th September+

Sat-28th September

PHASE - 2

COMMUNITY ORAL HEALTH CENTER (जन दन्त स्वास््य कें द्र)

Established By Jan Swasthya Sahayog (JSS), Ganiyari

In association with Department Of Community Dentistry, New Horizon Dental College and Hospital (NHDCH), Sakari, Bilaspur

Services begin on 2nd September 2013


PHASE - 2

Infrastructure @ Clinic:

1. 1 Operating room with complete clinical set-up (for

2 dental chairs) and 1 attached waiting room for

patients

2. Electricity and Water connections

3. 2 Dental Chair with all attachments

4. 1 Radiograph machine

5. Infection control equipments/ materials


EVALUATION OF INTERVENTION

1. Training Evaluation : Retention of Knowledge

of Trainee

2. Community oral health screening camps

3. Clinical Services Outcome Evaluation


Training Evaluation

(Retention of Knowledge of Trainee)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

100%

75%

100%

38%

87%

100% 100% 100%

75%

100%

75%

100%

37%

75%

25%

0%

75%

62%

87%

50%

57%

87%

37%

75%

Levels of knowledge (Cluster Co-ordinator)

(% of Pre and Post Intervention responses in various topics of training)

CC (PRE INTERVENTION) - CORRECT RESPONSES CC (POST INTERVENTION) - CORRECT RESPONSES


Respondents

CC (PRE INTERVENTION)

% Response Don't Know

CC (POST INTERVENTION)

% Response Don't Know

Improvement (%)

1 28 9 19

2 13 0 13

3 16 0 16

4 3 0 3

5 9 3 6

6 13 0 13

7 3 3 0

8 3 0 3

Mean 11 1.875 9

Respondents

CC (PRE INTERVENTION) CORRECT RESPONSES

CC (POST INTERVENTION) CORRECT RESPONSES

1 13 23

2 22 28

3 22 31

4 18 30

5 18 23

6 20 30

7 23 23

8 26 28

Mean 20.25 27

Paired Samples Test

Paired Differences t df Sig. (2-tailed)

Mean Std. Deviation Std. Error Mean 95% Confidence Interval of the

Difference

Lower Upper

Pair 1 CC (Pre) –

Cc (Post) -6.750 4.234 1.497 -10.290 -3.210 -4.509 7 .003



0

2

4

6

8

10

12

14

Levels of knowledge (Senior Health Worker) (Pre and Post Intervention responses in various topics of training)

Respondents

SHW (PRE

INTERVENTION)

CORRECT

RESPONSES

SHW (POST

INTERVENTION)

CORRECT

RESPONSES

1 15 30

2 21 22

3 10 22

4 24 28

5 21 30

6 19 22

7 23 28

8 18 23

9 16 28

10 18 31

11 23 27

12 21 23

13 10 26

Mean 18.38462 26.15385

Respondents (PRE

INTERVENTION)

% Response

Don't Know

(POST

INTERVENTION)

% Response

Don't Know

IMPROVEMENT(

%)

1 30 3 27

2 9 3 6

3 6 3 3

4 6 0 6

5 22 3 19

6 10 3 7

7 16 0 16

8 9 5 4

9 3 0 3

10 6 0 6

11 16 0 16

12 9 6 3

13 31 3 28

Mean 13.30769 2.230769 11.07692



Community oral health screening camps

EVALUATION OF INTERVENTION/ ANALYSIS

Clinical Services Outcome Evaluation

Clinic remains open for 6 days in week (Mon to Sat)

Human resource at work:

1. Dental Surgeon – B.D.S. (1) comes from NHDCH *

2. Nurse – A.N.M. Intern (1) on rotation basis come from JSS # – (School of community nursing)

3. Junior Dentists – B.D.S. Interns (4) on rotation basis come from NHDCH

4. HELPING STAFF (1) from JSS

*NHDC = New Horizon Dental College and Hospital, Sakari, District - Bilaspur

#JSS = Jan Swasthya Sahayog (Peoples Health Support Group), Ganiyari, District - Bilspur



Services Provided

Since 2nd Sept 2013 till 11th Oct 2013

Number of working days = 27

No. Of Patients Registered = 176

New patients = Came to JSS with chief complaint of oral health problem

Old patients = Previously registered @ JSS, Health centre for other health problem


New

patients ,

115, 65%

Old Patients,

61, 35%

NEW AND OLD PATIENTS


Total Newly registered patients = 115

Registered Common Chief Complaints:

1. Pain in teeth

2. Bleeding gums


male , 64, 56%

female, 51, 44%

REGISTERED PATIENTS



26

33

42

0

5

10

15

20

25

30

35

40

45

Chronic Periodontitis Chronic Irreversible Pulpitis Chronic General Gingivitis

Common Diseases (Total = 101 Patients)



11

17

22

6

0

5

10

15

20

25

RCT EXTRACTION SCALING RESTORATION

Series1

Total number of patients treated = 56

115

101

56

0

20

40

60

80

100

120

140

Registered Confirmation of diagnosis Recieved Treatment

Nu

mb

er

of

Pa

tie

nts

Patient Retention

Series1


101, 88%

14, 12%

PATIENT ATTRITION - 1

Confirmation of diagnosis Droped before complete diagnosis

56, 55%

45, 45%

PATIENT ATTRTION - 2

Recieved Treatment Droped after diagnosis but before treatment

CONCLUSIONS

IEC material that was prepared in picture flip-book form, book in local language, and audio-

visual materials used for training are effective tools for training of Community Health

Workers in oral healthcare

CHW trained in oral health have become one of the comprehensive health care team members

who can identify oral health problems and make appropriate referrals for those patients who

are in need of oral/ dental healthcare services

Community has an increase in access to oral healthcare services

Community clinic is now consistently attracting new patients

Clinical services are accessible to the community

Patient attrition should be analysed and study should be done to find the reasons behind

attrition so that patient could be retained in services

LAUNCHING A NEW CADRE OF

“COMMUNITY ORAL HEALTH WORKERS

(COHW)” WITH EXPANDED FUNCTION

REFLECTIONS

REFLECTIONS

The prototype which is ready now, can be useful at

larger level to Create a new cadre of middle level

oral health workforce

Expanding scope for “Oral Health for all”

A new cadre

Community Oral Health Workers

(COHW)

OTHER INITIATIVES PROPOSED

Internship opportunity for Community Oral Health Professionals

Regular training of the CHWs and evaluation

Community Oral Health Screening Camps

Mobile Oral Health Clinic

INNOVATION IN ORAL HEALTH CARE - COHW-report presentation

Health & Medicine

Transcript of INNOVATION IN ORAL HEALTH CARE - COHW-report presentation