Cascading Key Oral Health Messages to Remote and Rural Northern Malawi
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FRRHH has had the privilege of supporting NGO Bridge2Aid with some inspiring events aimed at improving global remote and rural healthcare. The faculty is now excited to share a report about a pilot project developed by Bridge2Aid, Smileawi and the Dental Association of Malawi, and the Malawian Ministry of Health. The project aims to train medical assistants in rural areas of Northern Malawi to promote oral health and to provide simple emergency dentistry.
Oral diseases like dental caries and periodontal disease, despite being mainly preventable, are amongst the most prevalent noncommunicable diseases (NCDs) globally, with significant health and socio-economic consequences.  With limited resources for prevention low-and-middle income countries (LMICs) have the highest burden of oral disease. Oral diseases are caused by modifiable risk factors like dietary sugar, smoking, alcohol, poor hygiene, and underlying social determinants.  These are common risk factors shared by the four main NCDs; diabetes, heart disease, lung disease and cancer.
In a recent historic resolution, the World Health Assembly urged:
“Member States to address key risk factors of oral diseases shared with other NCDs such as high intake of free sugars, tobacco use and harmful use of alcohol, and to enhance the capacities of oral health professionals”.
This resolution, which prioritises oral health, is welcome news for LMICs and NGOs like Bridge2Aid and Smileawi who have for many years been attempting to tackle oral health inequalities in sub-Saharan Africa (SSA).
Prior to the Covid-19 pandemic, the NGOs Bridge2Aid and Smileawi, collaborating with the Dental Association of Malawi, and the Malawian Ministry of Health, planned a pilot hands-on training programme to task-shift Medical Assistants in rural areas to promote oral health and to provide simple emergency dentistry in line with the Basic Package of Oral Care . Bridge2Aid have successfully used this model in Tanzania training nearly 600 rural health-workers over 15 years. Funded by a Scottish Government, grant to Smileawi the programme was planned for June 2020, however due to the pandemic it was cancelled. Fortunately, the Scottish Government allowed the grant to be re-tasked to support another pilot project aimed at developing an online educational course for dental therapists in northern Malawi.
The aim of the online training course was to upskill dental therapists in northern Malawi regarding the relationship between oral health and NCDs and to train them to deliver key oral health messages into remote and rural areas, using the cascade method.
This project was a collaboration involving Smileawi, Bridge2Aid, the Dental Association of Malawi, ProDentalCPD, the Corra Foundation, the Maldent Project, Malawi Government, Scottish Government, and the Universities of Dundee and Glasgow. Working in partnership, the combined expertise resulted in a programme that exceeded expectations.
There are approximately 43 dentists and less than 300 dental therapists in Malawi for 19 million people. In most rural areas there is neither access to oral health messages nor dental care. Dental therapists are best placed to address oral health in rural areas. Therapists were originally trained to promote oral health, but due to lack of dental professionals they are now primarily tooth extractors with health promotion secondary. (See Figure 1) In addition, few have any knowledge of teaching and learning methods.
Figure 1: Over 80 rural patients await tooth extractions from a therapist.
The main course content included updating of oral health knowledge, focusing on relationships between oral health and NCDs and development of teaching skills to facilitate effective delivery of oral health messages to different community workers like health workers, elders, teachers, traditional healers and youth workers. Following consultation with the Dental Association of Malawi and Ministry of Health the course addressed other priority areas. For example, an oral health survey is being conducted in Malawi soon, so the therapists were taught about survey importance and how to conduct a WHO survey. The course also dealt with WHO Afro priorities like Noma and Infant Oral Mutilation. Finally, the course addressed issues often overlooked in SSA like oral health promotion to disabled people and those with epilepsy or albinism, who may sometimes be subjected to marginalisation, due to cultural myths and beliefs.
Course production was undertaken by Bridge2Aid and Smileawi volunteers, who had significant cross-cultural experiences in SSA with many having educational backgrounds. A 12-module course was designed using short presentations to keep data costs low using additional resources like quizzes and videos. Therapists were taught about learning styles, motivational interviewing, time management, teaching practical skills, feedback, reflection, self-assessment, and peer assessment to empower them to train others to cascade key messages (See Figure 2).
Figure 2: Slides in presentations were simple and culturally appropriate.
Review and Production Process:
All material was checked by two senior Malawian dentists for cultural competence. One dentist was primarily responsible for local management of therapists and on-site course logistics. The other focused on seeking appropriate permissions from the Ministry of Health and CPD approval from the Medical Council of Malawi. There was additional input from a Malawian PhD student and Smileawi sponsored therapy students from the Malawi College of Health Sciences, who produced toothbrushing videos using WhatsApp. Material was reviewed by multiple members of the team and checked to ensure the script was in plain English which is the therapists’ second language. A UK dental CPD provider ProDentalCPD Zoom recorded presentations and a test module was tested by three therapists in various rural settings in northern Malawi. Following testing Zoom recordings in low-resolution video had the most benefits and least problems (See Figure 3). Once all modules were recorded ProDentalCPD provided accounts on their CPD site for the therapists so material could be delivered to loaned tablets purchased with the grant. A WhatsApp support group assisted them with technical or other issues. The grant allowed for 3 months of Data for each therapist so the course could be completed.
Figure 3: A course tutor teaching an oral cancer self-check on low resolution Zoom video.
The therapists completed pre and post-course questionnaires. Feedback was invited for each module which was largely positive with participants feeling their knowledge of relationships between oral health and NCD's was much increased. Feedback exposed gaps in knowledge regarding oral cancer with the belief that cancer diagnosis was an instant death sentence. The course addressed the importance of early detection and diagnosis. Confidence ratings indicated improvements in therapists’ assessment of their oral health knowledge and an increased confidence to teach and cascade messages to individuals and diverse groups.
The project identified several barriers:
1. Digital poverty: Data costs in Malawi are high and disproportionate to income. Lack of IT skills were a problem initially, with a minority struggling throughout.
2. Network issues: Slower download speeds and loss of sound occurred occasionally.
3. Sustainability: Whilst the grant permitted purchase of loaned tablets this would be unsustainable if the course was rolled out to a wider region, so ongoing delivery will be sustainable only if delivered to mobile phones. Most participants own a mobile phone, but these are generally obsolete devices and testing is currently underway to determine modifications needed for course delivery to these devices.
4. Resources: Props and teaching materials such as dental models are helpful for teaching and these will need additional funding.
5. Infrastructure and Climate: The rural road system is primarily unpaved roads and bicycle the main form of transport (see Figure 4). Motorbike taxis and buses are infrequent and unreliable, and unpaved roads are very susceptible to weather. In the rainy season many rural areas are inaccessible.
6. Time: The therapists already have many demands on their time, travel times and distances are large, so this will add to their workload.
7. Covid-19 restrictions: Are currently a temporary barrier to access rural areas.
8. Community Resistance: There may be local resistance to the programme, making it harder to recruit local community workers to cascade oral health messages. For example, some traditional healers have different views on oral health and hold positions of authority within local communities.
Figure 4: Access to remote and rural areas is challenging.
There were many benefits identified. The therapists felt better able to teach others to teach. They felt that the course increased their general confidence, updated their oral health knowledge, increased their self-esteem and standing in their community and gave them job satisfaction. The course appeared to inspire the therapists to teach. Additionally, the course cemented relationships between oral health stakeholders in Malawi which can only benefit the nation in the future. CPD is a relatively new concept in Malawi so course CPD approval from the Medical Council of Malawi for one year’s worth of CPD for the therapists was greatly beneficial.
Planning is underway for course roll-out to dental therapists throughout Malawi soon. This training course has potential for use in remote and rural areas in the wider SSA region. But, SSA is a large region with distinct cultural and community groups and what works for one area may not work for another, so if it is used more widely local advice, oversight and collaboration is essential for culturally appropriateness at the point of delivery.
The course has drawn attention from WHO Afro region who are planning some e-learning based on their document “Promoting Oral Health in Africa” which they hope to deliver to 47 African nations. Some of the main stakeholders in this course have been asked by WHO to input and collaborate with them which is indeed a positive development for Oral Health in Africa.
PgCert (MedEd) BDS LLM FDSRCPS FDS DRD MRDRCS(Ed)
Senior Clinical Lecturer/Honorary Consultant in Restorative Dentistry, Dundee Dental School
Chairperson, Clinical Advisory Group, Bridge2Aid
BDS, PhD, MSc Com Dent Health, MSc Med Ed, MFDS (RCS Edin), DDPH (RCS Eng), Dip Con Sed
Associate Specialist/Honorary Clinical Lecturer in Sedation/Special Care Dentistry, Newcastle University School of Dental Sciences
CEB Cert in Dental Hygiene, Dip DHE (RSH)
Dental Hygienist, Glansevern Periodontal Centre, Welshpool, Powys
General Dental Practitioner, The Hollies Dental Practice, Dunoon and co-Founder of Smileawi
General Dental Practitioner, The Hollies Dental Practice, Dunoon and co-Founder of Smileawi
- World Health Organization (2020). Oral Health. 25th March 2020. Available from: Oral health (who.int)
- World Health Organization (2021). World Health Assembly Resolution paves the way for better oral health care. [online]. 27th May 2021. Available from: World Health Assembly Resolution paves the way for better oral health care (who.int)
- World Health Assembly (2021). Oral health. WHA74.5. [pdf]. 31st May 2021. Available from: Oral health (who.int)
- Baart J, Bosgra J, and van Palenstein Helderman, W. (2005). Basic oral emergency care by auxiliaries for underserved populations. Dev.Dent. 2005:6.
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