Oral Health Promotion Intervention In Rural Contexts: Impact assessment. Córdoba, Argentina. ORIGINAL ARTICLE - PDF

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Journal of Oral Research ISSN Print ISSN Online ORIGINAL ARTICLE Lila Cornejo, Elena Hilas, Irma Moncunill. Facultad de Odontología, Universidad Nacional de Córdoba,

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Journal of Oral Research ISSN Print ISSN Online ORIGINAL ARTICLE Lila Cornejo, Elena Hilas, Irma Moncunill. Facultad de Odontología, Universidad Nacional de Córdoba, Argentina. Receipt: 03/06/2014 Revised: 03/18/2014 Acceptance: 03/26/2014 Online: 03/26/2014 Corresponding author: Phd. Lila Susana Cornejo. Facultad de Odontología. UNC. La Haya s/n. Ciudad Universitaria. Pabellón Argentina. Estafeta 32. CP Córdoba. República Argentina. Fax: Oral Health Promotion Intervention In Rural Contexts: Impact assessment. Córdoba, Argentina. Cornejo LS, Hilas E & Moncunill I. Oral Health Promotion Intervention In Rural Contexts: Impact assessment. Abstract: Introduction: The study was carried out in Cruz del Eje Department, Cordoba Province, Argentina. It was based on diagnosis of conceptions of health, concentration of fluoride in drinking water and accessibility to dental coverage in 71 rural schools. Additionally, parents and teachers conceptions of general and oral health, dental clinical status and sialochemistry of students from eight schools were considered. Objective: To evaluate a community intervention strategy for promoting oral health in rural contexts. Through the participation of the teacher as a mediator of healthy pattern, this strategy was developed. Methods: In order to elaborate oral health promoting strategies, educational workshops, epistolary communication and on site tutorials meetings were implemented. Specific health projects to be added to the Educational Institutional Programs, as a contextualized mediating strategy for promoting oral health were designed by teachers. The strategy was evaluated comparing dental caries increase (CI) detected the previous year and the one following the implementation of the educational plans. Mac Nemar's test was applied, and p 0.05 was set to indicate statistical differences between both periods. Results: A 30.43% CI (p 0.0001) was observed the year before implementing the educational programs as well as a CI reduction to 17.39% (p=0.0002) a year after their application. Conclusion: The drop off in 57.14% of the CI in rural areas, confirms the intervention strategy of designed for this particular context. Keywords: community intervention, oral health promotion, rural communities. Intervención para la promoción de salud bucal en contextos rurales. Evaluación de impacto. Córdoba, Argentina. Resumen: Introducción: El trabajo se desarrolló en el Departamento Cruz del Eje, Córdoba, Argentina, en base a diagnósticos sobre concepciones de salud, tenor de fluoruro en el agua de bebida y accesibilidad a la cobertura odontológica realizado en 71 escuelas rurales, y sobre concepciones de salud general y bucal de padres y maestros, estado clínico odontológico y condiciones sialoquímicas de escolares de 8 escuelas. Objetivo: Evaluar una estrategia de intervención comunitaria, para la promoción de salud bucal en contextos rurales, desarrollada a través de la participación del docente como mediador de pautas saludables. Material y método: Para el desarrollo de las estrategias de promoción de la salud bucal se implementaron talleres docentes, comunicación epistolar y encuentros tutoriales en terreno. Los maestros diseñaron proyectos específicos de salud integrados en los Programas Educativos Institucionales, como estrategia mediadora contextualizada de promoción de salud bucal. Se evaluó la estrategia comparando el incremento de caries (IC) detectado en el año previo y en el siguiente a la implementación de los planes educativos. Se aplicó la prueba de Mac Nemar, fijando p 0.05 para indicar diferencias estadísticas entre ambos períodos. Resultados: Se observó 30,43% de IC (p 0.0001) en el año previo a la implementación de los planes educativos y una reducción del IC al 17,39% (p =0.0002) al año de comenzada la aplicación de los mismos. Conclusion: La disminución en un 57,14% del IC en los escolares rurales, valida la estrategia de intervención construida para estos contextos particulares. Palabras clave: intervención comunitaria, promoción de salud bucal, comunidades rurales. Introduction. Dental caries is one of the most widely disseminated diseases worldwide. In most developed countries, preventive measures have significantly reduced its prevalence in the past 20 years 1-4. However, in developing, and some developed countries regions, especially those of low socio-economic status, both rural and urban, implemented preventive actions have not had the expected impact 5. On the one hand, one of the responsible factors for this is that, in some cases, programs have not been systematically implemented. On the other hand, these programs are not based on an indepth analysis of the health-disease-care process from a contextualized attitudinal perspective 5. Generally, implemented actions respond to extrapolated models which do not meet the needs of each community; instead, they seek homogenization by using methods and contents which are not according to the idiosyncrasies thereof. Several epidemiological studies, performed at a global, regional and national level, show that in rural, remote and socioeconomic disadvantaged groups a higher caries prevalence occurs. This suggests that determinants exceed biological realms. In Colombia, Escobar et al. 6 reported that 40 60.44% of five-year-old children have history of dental caries in primary dentition. Meanwhile, Rivera Martinez 7 registered 49.2% caries prevalence in pre- school children from a Chilean rural area, which whom also had a 2.4 dmft score (SD 3.5). Therefore, he proposed to intensify oral health promotion/education efforts, along with adding care resources to reduce the impact of oral diseases in the future. In studies concerning the oral health of children from a rural area of Tupungato Mendoza, Argentina 8, a high severity level of caries prevalence was detected (dmft+dmft)=4.64. In rural areas of northeastern Argentina, a caries prevalence 8 of 64%, with varying degrees of severity and an average of four permanent molars lost at the age of ten, was reported. In rural areas of Cordoba, 49% to 90% caries occurrence was detected 9, 10. Any preventive strategy involves cultural contents that the subject has to grasp. In relation to this, Vygotsky assigns a key role to mediators The context in which people develop is essential; then, the school becomes one of the main mediators in the process of cultural appropriation In rural areas, where population density is low and families are unrelated, with inadequate roads and transportation, the school is an inviting center for recreational and cultural activities. In this context, teachers constitute the major mediators of cultural patterns, including health promotion and disease prevention 15. In the 90s, in Argentina, the economy of arid and semiarid rural areas, such as the Department of the Province of Córdoba, suffered a noticeable depression, with the consequent negative impact on the community health status. This makes it necessary to restore the school as a center for health promotion and teaching as an effective mediator for healthy practices. The interactionist sociological approach 16 believes that health is a concept constructed by a subject from his interaction with the environment. In relation to the healthdisease-care process at the oral component level, it is worth to investigate representations of general and oral health of the subjects whom integrate the community and the health practices they implement. The geographic, economic and/or cultural health services accessibility, particularly dental care, is another factor of interest within the socio-cultural dimension, due to its impact on the appropriate use of health services and consequently in the dynamics of the health-disease-care process 17. From the perspective of the interactionist model of health-disease-care process, in which interrelationships between different biological, physical, environmental and socio-cultural dimensions generate great interest, the community was intervened to develop and implement mediating strategies for oral health promotion. Built on the basis of an interdisciplinary diagnostic, which include the different involved dimensions, such as concepts of general and oral health, preventive practices, dental clinical aspects, eating behaviors, access to medical and dental care and environmental conditions, were meant to meet the strengths and needs of the communities. In this paper, the effect of a community intervention to promote oral health, developed by the teachers as healthy patterns mediators, in depressed socio-economically rural areas in the north of the Córdoba Province, in Argentina, is evaluated. Materials and methods. An intervention longitudinal study focused on participatory action research was performed. The study involved rural schools from Cruz del Eje Department, Province of Cordoba, Argentina. This context is characterized by low population density, geographic isolation and depressed economy. Educational communities are comprised of unrelated families, distributed in scattered hamlets, located between 70 and 90 km. away from urban centers, which have in some cases muddy impassable roads during rainy days. Schools are mostly multi-grade and staffed by a single teacher (ST). Teachers live in the same educational facility where students are given breakfast and lunch. School enrollment is low, between ten and twenty children, from three or four families in some cases. The intervention was developed in three phases: diagnostic, development and implementation of oral health promotion and evaluation strategies. The appropriate methodological approach for each analyzed object was applied. Ethical guidelines of the Faculty of Dentistry from Universidad Nacional de Córdoba, in accordance with the Declaration of Helsinki, were taken into consideration. Teachers and children s caregivers gave their written informed consent. Diagnostic stage - In 71 rural schools, the fluoride content in drinking water was analyzed with the electrochemical 16 method. - Teachers (n=129) completed a questionnaire with open-ended questions designed to identify concepts, preventive practices and educational activities related to health. The information collected was analyzed by saturation of information Statistical data from the Health Ministry of Cordoba Province, to relieve dental care offers and thier complexity level from the regional public health institutions, was analyzed. In addition, data from the Provincial and Regional Dental Circle provided, with the number of dental professionals in activity, on the region, was taken into account. - Representations about health services access, built by patients and dentist practitioners, through semi-structured individual interviews, applied in the waiting room of health centers to them, were investigated. In all cases, interviews were recorded in order to later proceed to their transcription on paper. Speeches were analyzed in individual and group 41 Table 1. Objectives and methodology used in the teachers workshops. reading to establish descriptive coding and construct explanatory matrices for recurrences The sample was comprised of eight schools which were randomly selected by choosing one out of five registered institutions in Cruz del Eje Department. The following evaluations were performed: Dental clinical evaluation. Children were examined in well-lit rooms with natural light in the schools, following the touch-visual routine procedure by three previously calibrated dentists (level of inter and intra-examiner agreement Kappa: 0.85). The number of decayed, filled and lost teeth or indicated extraction in primary and/or permanent dentition was recorded. For the diagnosis of caries and the dmft and DMFT indices determination, as well as for diagnosing malocclusion, WHO criteria 19 were considered. Fluorosis was assessed according to Dean 20 and Simplified Oral Hygiene Index by Greene and Vermillon 21. Sialochemical analysis. Stimulated mixed saliva and salivary flow (vol/min) were assessed and ph was determined electrochemically in children. Adittionally, as described by Cornejo et a.l. 10, buffer capacity, total protein concentration, calcium and phosphorus were evaluated. Parents and teachers health practices. Semi-structured individual interviews with health themed scripts were applied in a casual sample of 25 parents from eight school communities under study getting ten hours of recording. All teachers (24) were also called to be interviewed, out of whom 20 (16 women and 4 men) agreed to participate in the study signing written informed consent, yielding a total of 15 hours of recording. The information obtained 42 was the corpus of discursive data. While it was open information, using the constant comparative method, recovering the most significant speech expressions 18, through the transcriptions of written records, a qualitative analysis was performed. Later, descriptive codes assignment, preparation of explanatory matrices and determination of categories for problem interpretation followed. Development and implementation of educational plans. With the purpose of providing advice and assisting teachers in designing educational plans and contextualized strategies to promote oral health, workshops and tutorials were developed. Teachers workshops: The use of workshops to design health promotion strategies, was considered, including other voices as the most appropriate, due to they allow the generation of working methods, which respect the logic of production, circulation and appropriation of knowledge that involves the entire learning process 22. They were conducted in three instances and coordinated by members of the research team. Information on oral health was focused on four basic areas for the promotion of oral health: dietary habits, hygiene, regular visit to the dentist and the importance of fluorides. In the first workshop results of the diagnosis of the studied dimensions were reported and work was done on contents about interacting factors in the etiology of the caries process. In each workshops, teaching resources, specifically developed by the research team, taking into consideration the weaknesses identified in the diagnostic phase, were used. It was provided reading material selected for this purpose related to: concepts and paradigms of health, oral biochemistry, scope and importance of nutritional assessment, oral cavity, levels of preventive health, preventive dentistry, strategies and resources for oral health implemented by PAHO in different Latin American contexts. The objectives and methodology used in each workshop are presented in Table 1. Tutorials: As of strengths and weaknesses, identified in the development of projects by the team, a support system was implemented through epistolary communication and on-site mentoring. Each teacher, assisted by the research team with his students, implemented the project he developed. To track them, distance tutoring, complemented with a visit to each school, was carried out. Intervention evaluation. A longitudinal study evaluated the effect of the oral Figure 1: Caries prevalence at the three stages of the study. Figure 2: Caries increase after 12 months without implementing the educational plan and 12 months from its beginning. health intervention in rural school through the variation of two indicators: caries increment (CI) and simplified oral hygiene index (OHI-S), at the end of 12 months, without the application of educational plans and 12 months after their implementation. At all times, clinical examination was performed under the same conditions described for the diagnostic stage. All children, from five to fourteen years old, both genders, attending the sampled schools (n=199), were included in the diagnosis study. In the end, 46 students remained in the longitudinal study. Egress, migration or absence the day of the visit of the dental team produced sample attrition. High sample attrition did not allow maintaining age stratification in the longitudinal analysis. After the first and second year of the study by the nominal variable new cavities (NC), whose categories were established as: NC: 0 (no new caries) and NC: 1 (with new caries), caries increment was assessed. To know statistical significance for each study period, McNemar test was applied, setting p 0.05 value to indicate significant differences. Data was processed with Infostat Professional version 1.1 for Windows Results. Results of the diagnostic status of the different dimensions involved in the study, opportunely published 10,23-27, highlighted important differences between educational communities regarding: sialochemical clinical indicators, fluoride concentration in drinking water, geographic accessibility to health services, allowing to establish associations between the different studied parameters. In relation to parents and teachers concepts of general and oral health, a significant healing trend was observed in all communities. In oral health, parents have symptomatic and resigned attitude towards disease, prevailing extraction culture and self medication 28. Teachers health representations are strongly linked to curative factors affecting their both behaviors when facing their own health and disease processes, and the actions they take in their role as socio-cultural animators 29. As for dental care services, offers proved to be insufficient and extraction was predominant. From the study of patients health services accessibility representations, it is inferred that the main determinant of the curative value, in the patients dental demand, is the healing conception, historically constructed 30. Characterization of communities considering dental clinical, socioeconomic, cultural and biological aspects was the foundation on which teachers, coordinated by the interdisciplinary team, designed educational plans to promote oral health. Different grabbing levels of the specific contents of oral health were observed among teachers. The production level of educational plans by teachers was uneven. While some developed a specific plan included in the Programa de Educacion Institucional (PEI), others only performed isolated actions. Prevalence of dental caries in the three stages of the study is shown in Figure 1. Although a lower prevalence of dental caries was found after a year of the educational plans implementation in relation to the period without intervention (93% versus 96% respectively), the difference between the two assessments was not statistically significant (p=0.687). In relation to caries increment, the number of CN showed a significantly higher increase (30%) during the first 12 months of the study without implementation of the educational plan, compared with an increase (17%) (p=0.0002) observed during the next 12 months being under educational plans (Figure 2). Comparison of children oral hygiene status (OHI-S) between the two evaluation times was significantly lower (p 0.001) for the OHI-S index in the second evaluation. None of the indicators showed significant gender differences (p=0.078) at the time of study. Discussion. The present study was conducted in educational economically depressed communities from semi-arid rural areas in the Northern regions of the province of Córdoba, Argentina. The residents of these communities can be considered of low socioeconomic status, according to their level of education and wage income. Most of them have 43 only received complete - or incomplete - primary education. Women serve as homemakers and men as laborers without a stable job. The variability observed between the education level of the studied rural communities and students dental clinic parameters 23, cannot be attributed solely to socioeconomic factors, as in all the studied communities, unfavorable socioeconomic characteristics are presented in a homoge
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