“Reaching School Children with Portable Dental Units to improve access and prevent Tooth Decay”
School Oral Health Program, Kuwait-Forsyth

The Problem

After the war in 1991-1992, Kuwait witnessed a major economic boom which led to incorporation of unhealthy lifestyle practices which was naturally acquired by children. One of the unhealthy practices among the population here is the high consumption (almost 40 Kg/annum according to WHO) of sugar rich food stuffs. This has been the most important reason for the high prevalence of tooth decay among children here.

National Oral Health Survey for school children in Kuwait was conducted in 2004. Surveys are part of the outcome evaluation procedure performed at SOHP once in 5-6 years. This survey revealed that prevalence of Dental Caries in Primary teeth was more than 80% and that in Permanent teeth was almost 60%. This survey also revealed that children receiving regular prevention and care had significantly less tooth decay. Hence, there was an urgent need to reinforce the prevention and education program that existed with some innovative ideas so that majority of the children can receive regular prevention and care.

Majority of the oral health care delivery system that existed at SOHP prior to 2005 was either through a center-based system of polyclinics exclusively for children and School-based clinics, fixed dental clinics within the school premises. Only around 1/10th of the schools had a dental clinic where the children belonging to that school received prevention and treatment. Children belonging to other schools (without clinics) were taken in buses to SOHP centers in the morning for oral health prevention and education. This type of arrangement was not only time consuming but had other limitations as well, for eg: if a particular student was absent (rate is high in Kuwait) he missed out on this service. At the same time there was time wastage due to travel and also children lost a lot of school hours. Hence time spent on prevention was less and at the same time a lot of time was spent in treating the disease because of the ever increasing disease burden. Majority of the resources were utilized for treatment rather than prevention prior to 2005-2006.

Majority of the parents (almost 80%) of these children are public sector employees, hence a lot of their time would be lost if their child belonged to a school without dental clinic and was not covered with prevention either. Hence, they had to leave their work and accompany their children to SOHP centers in the morning for treatment whenever their child had a tooth problem. Hence, so much of the working hours of these parents were lost which was in turn a national loss. Also, the school absenteeism of the children was on a higher side because of the tooth problem. Hence, there was a great need to shift the focus from center-based approach to mostly school-based during the school hours and also from treatment to prevention and education.

Hence, strategies to reach out to these children (age group of 4-16 years) within the schools had to be reworked in order to minimize the problems faced.

Solution and Key Benefits

 What is the initiative about? (the solution)
The core aspect of this initiative is the effective use of Portable Dental Systems to cover more children/schools with prevention. Portable Dental Systems utilized at SOHP are of 2 types: 1) Type A: This is a complete set of portable system which simulates a dental clinic but is portable. This type of Portable system is utilized at SOHP for application of Fluoride Varnish and placing preventive restorations (Pit and Fissure Sealants) 2) Type B: this type of Portable dental systems comprise of simple foldable Dental chair and portable dental light along with the operator and assistant stools. This type of Portable units is used for applying fluoride for school children.

After obtaining the required approvals from Ministry of Health and Ministry of Education and making the required policy changes SOHP decided to procure these Portable dental systems that would be used as mobile teams to provide primary oral health prevention for school children in the age group of 4 to 16 years in Kuwait. On an average SOHP procured almost 10 Type A units per year to the current fleet strength of almost 50. At the same time there is almost the equal number of Type B portable units too.

A dentist along with 2 nurses and a type A portable system formed a prevention mobile team (Performs Sealants and Fluorides). Whereas Dental Hygienist/Dentist with one nurse and Type B portable system formed the second type of prevention mobile team (Fluoride application only).

The main purpose of this initiative was to provide Primary oral health prevention and education to children belonging to schools without dental clinics within the schools. As the result of this children from these schools were not required to move to SOHP centers in the morning hence, amount of school time lost was significantly reduced.

Since, each mobile team with Type A system would cover children in 4-6 schools (depending on the school size) and the mobile team with Type B system would cover children in 10-15 schools, our prevention coverage increased significantly with each passing year. All these children belonged to schools without clinics who otherwise were not sure of getting prevention before 2006. Also, since these teams were within the schools they could also cover children who were absent on a particular day when they joined back.

Parents did not have to leave their work since their children received these services within the schools. Also, children who require further care get a referral card asking their parents to take their children to SOHP centers in the evening.

Another important achievement of this cost-effective initiative has been in creating awareness about the importance of oral health prevention among children and their parents. This has immensely helped us to improve our consent return and hence prevention coverage.

Hence, this initiative has helped us to gain control over our problems in different ways and helping immensely in reducing the burden of dental disease among Kuwaiti school children.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
This initiative was initially proposed by Assistant Undersecretary for Dental Affairs at MOH, Kuwait and Senior Consultant from Forsyth Institute, Boston during 2005-2006.

Designing of the initiative along with policy development was the responsibility of the Oral Health Superintendent from MOH, Kuwait and the Program Director, who represents Forsyth Institute in Kuwait. Development of the plan took some time since we had to look into various aspects involved. It involved series of meetings with the various heads and clinical supervisors of SOHP.

Once the policy was finalized the next step was implementation of the services. Plan was to go for phase-wise expansion every year. Required portable equipments and materials for 2006-2007 was ordered through our purchasing department.

Education department in various governorates provided SOHP the required permission to carry out this initiative. Permission was obtained from the participating schools through the school principals who provided space and other facilities to set up these portable systems within the school premises.

Maintenance technicians belonging to SOHP were responsible for transporting these portable units to the schools and setting them up in the space provided. They were also responsible for maintaining these units in good condition.

Personnel involved in carrying out the services were trained Dentists, Dental Hygienists and Dental Nurses. In each of the governorate they were supervised by Prevention Team Leaders and Health Education In charges.

Hence in each of the six governorates of Kuwait where SOHP operates it is managed by a program head who has a clinical supervisor, prevention team leader and health education in charge to manage various services offered under SOHP.

Also, these prevention mobile teams were well supported by the supplies department, providing the needed supplies on regular basis without delay and also the printing department provides health education materials to the children.

Health education department provided the needed media coverage and support for this initiative which was important for its success.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The main objective of this initiative was to increase coverage of children with prevention by improving access for prevention through effective use of Portable dental systems. When the main objective was accomplished it helped in achieving other secondary objectives. Another important objective of this initiative was to prevent and gain control over Dental Caries. Other secondary but very important objectives which were closely associated with the primary objective were, increasing awareness about oral health prevention among children, parents and school teachers. To reduce the school time lost for each child due to oral problems was other objective of this initiative. Another important objective of this initiative was to make this initiative to act as a referral system to children requiring further oral care. There were many other objectives which we could achieve as this initiative moved on, the ones that were not planned to begin with.

SOHP had to decide on what type of prevention strategies that will be adopted to be delivered through mobile teams to the school children. Evidence-based successful prevention strategies against dental caries were adopted. Scientifically proven prevention methods against Dental Caries are: 1) Topical Fluorides and 2) Pit and Fissure Sealants. In Kuwait government doesn’t have policy for water Fluoridation, hence only form of Fluorides that can be put in practice are the Topical Fluorides. Among the Professionally applied Topical Fluorides the best evidence is available for Fluoride Varnish for prevention of Dental Caries when it is applied on teeth at least 2 times in a year. Pit and Fissure sealants were an automatic choice as the second option. Prevention teams with Type A portable system applied Fluoride Varnish and Sealants whereas teams with Type B portable units applied only Fluoride Varnish for the children. All the children with positive consents received biannual fluoride varnish application along with fissure sealants. Along with these prevention strategies these prevention teams would spend time on educating the children about the importance of oral health prevention.

Other strategies employed were redesigning our prevention policy with description of the functioning of prevention mobile teams. It also explained the job descriptions of the personnel involved in this initiative. Also 6 Prevention Team Leaders were appointed to carry out the initiative in 6 governorates of Kuwait. Changes were incorporated in our clinical protocol to include these changes. Another important strategy employed was designing of prevention charts to be used by mobile teams that would help in follow-up of children every year. Evaluation system to evaluate the process and quality of work was also put in place.

These strategies were devised due to collective efforts of Assistant Undersecretary for Dental Affairs from MOH, Oral Health Superintendent from MOH, Senior Consultant from Forsyth Institute and SOHP Director. They were implemented in each of the 6 governorates with the help of 6 program heads, Clinical Supervisors, Prevention Team Leaders and Health Education In charges. Personnel involving team of Dentists, Dental Hygienists and Dental Nurses were responsible for delivering the care in schools.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
Following steps were involved in development of this initiative:

1. Situation Analysis: During the latter half of the academic year 2005-2006. A detailed analysis of the existing situation was carried out. Existing problems were listed out along with the solutions. Prevalence of Dental Caries was referred from the oral health survey conducted on the school children during 2004. In short, SOHP needed to improve coverage of the children with prevention in order to control tooth decay.
2. Decision Making: After the situation analysis, a case was presented to Assistant Undersecretary, Dental Affairs and Oral Health Superintendent at MOH regarding the existing situation. They were made fully aware of the problems faced and something needs to be done soon. A decision was made to utilize portable dental units to cover schools without clinics with prevention. This way SOHP would be able to increase the number of children receiving primary prevention and hence control tooth decay. Since, these services were being planned to be carried out within the school it would have so many other benefits associated with it. At the same time this method was cost-effective compared to setting up a clinic within a school, this was a big plus when it came to final decision making. Final decision was made to go for a phase-wise expansion with these portable units every year.
3. Procuring the Equipments and Materials: During 2006-2007, 10 Portable dental units from Aseptico, USA were ordered and the local dealer was kind enough to provide us one unit free. Hence, SOHP had 11 units in the first year. Also, required type and quantity of materials were ordered and procured through our central purchasing department.
4. Prevention Policy: During 2006-2007 our existing policy for prevention was revised. Detailed section was dedicated to functioning of prevention mobile teams using these portable units. Details included on types of units, method of functioning within the schools, administrative issues and job descriptions of the personnel working in these mobile teams.
5. Staff Training: The selected staffs were trained in the operation and minor maintenance of these portable units by the technical personnel belonging to the maintenance team. Clinical training was provided by our training department.
6. Identification of Schools: Schools without existing dental clinics were identified and a plan was prepared to cover at least a part of them during 2006-2007.
7. Permission from Ministry of Education: Once the schools were identified the required permission from MOE was obtained to operate within the school premises.
8. Installation of the equipments: Once the school and the space were identified the maintenance technicians would transport the equipments to the schools and set up the equipments there and run a test when ready. Then the skilled personnel would move in with the required materials and perform prevention on school children.
9. Program Evaluation: This initiative was evaluated in terms of the process performed and the outcomes were measured qualitatively and quantitatively on regular basis as explained under previous question.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
Following were the major obstacles encountered during the course of this initiative:

1. From the Personnel: The selected personnel were not always willing to work in a mobile team using a portable unit, because this would not give them the comfort of a fully-fledged dental clinic. Also, since the teams had to move frequently from school to school some of the staff complained of the transportation issues.
Solution: Working in prevention mobile teams with portable dental units was made mandatory to all the staff working for SOHP. They were all made aware of the existing problems facing the children in Kuwait and the only solution is to cover them with effective prevention. All the staffs were convinced to work in mobile teams. Also, the staff working in mobile teams received a monthly transportation allowance which took care of their complaints regarding transportation. Performance-based incentive for the personnel working for mobile teams introduced since last 2 years has become very popular among the staff, urging them to work for mobile teams, cover more children and also maintain high quality.
2. From School Administrations: Some of the schools were not ready to provide our mobile teams the space and facilities to work in their schools, saying that it would interfere in their day to day affairs.
Solution: Administrators belonging to SOHP would explain in detail to the management of such schools and convince them to change their minds. In most of the cases we were successful in changing their decision.
3. Data Collection and Follow-up: This was the big obstacle SOHP faced during the first year of this initiative. Since this concept was new here there was not existent data collection methods for the services provided through mobile teams, hence it was difficult to obtain standard data from all the teams in 6 governorates.
Solution: During 2006-2007, an unique data collection chart to be exclusively used by mobile teams was designed, which would help in collecting data about the services provided and also give a picture about what to expect in future for that child. This would help these mobile teams to reach that child on time to prevent tooth decay. This chart was put on trial during 2007-2008 by all the mobile teams. Some changes were done to this original chart before the final chart was put into use during 2008-2009. Now we have standard reliable information coming from all the mobile teams working in all the 6 governorates for SOHP.

These were the major obstacles that this initiative encountered which was sorted out with collective efforts from all involved. There are day today problems/obstacles which these teams encounter on day to today basis but today after more than 6 years of initiation of this initiative people know exactly how the system works and where to look for the solutions. When these obstacles are weighed with the benefits, they are very much outweighed.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
This initiative was designed to be a cost-effective one. SOHP received entire financial support for this initiative from Ministry of Health, Kuwait.

Main categories of the expenses involved were those related to, 1) Equipments, 2) Materials and 3) Manpower. Other than these there were other minor miscellaneous expenses involved on day to day basis. Detailed budget with the plan was presented to MOH and it was promptly accepted and approved. In short, the unit cost involved for setting up a clinic with portable dental unit was less than 1/5th of that of a full pledged dental clinic.

Type of equipment required to start this initiative was decided by SOHP. MOH was kept informed before the purchase orders were placed. Same procedures were followed for the procurement of materials.

When this initiative began in 2006, utilized the existing personnel of SOHP to operate whether it was dentists, hygienists or nurses. Later on during the years of expansion more qualified manpower was hired according to the expansion plans. As of 2012-2013 there are almost 50 dentists, 25 hygienists and 120 nurses working for this initiative alone. Each mobile team working with Type A portable unit comprises of a dentist and 2 nurses whereas the team using Type B unit has one hygienist/dentist and one nurse to carry out the services.

In order to minimize the burden of cost involved, SOHP went for year-wise expansion of this initiative. Since 2006-2007 on an average SOHP expanded the teams by almost ten every year. Today, SOHP has a fleet of more than 50 Type A units and almost 40 Type B units, auditing of these units are done on timely basis in order to avoid delay and maintain their efficiency. This has helped us to have better control over the initiative.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
When this initiative began in 2006, there was a doubt in the minds of everyone involved whether it will sustain the test of time. With the strong backing from MOH we could overcome all these doubts, solve the problems and keep this initiative going strong.

Now this initiative is in its 7th year after inception and is going strong. Greatest challenge was implementing this cost-effective strategy in an economically rich country like Kuwait and changing the mindsets of the staff involved.

This is a national level initiative with these mobile teams functioning in all the 6 governorates of Kuwait. During 2012-2013 there are 45 functioning mobile teams with Type A units and 35 mobile teams with Type B units.

Ministry of Health has constantly backed SOHP with all kinds of support required for the success of this initiative. Most important of them all being the financial support required for acquiring the required equipment and materials required and for paying salary to all the personnel involved. Since 2006, every year this initiative was expanded with new equipment.

This initiative has been well accepted by the children, parents and school teachers too. Since this is carried out within the school, children are more comfortable with it. Parents are happy that their children receive effective prevention every year within the school which will ultimately reduce the incidence of tooth decay; at the same time their children get education on oral prevention. Teachers are very happy since there is a drastic reduction in the amount of school time lost when the children had to move to SOHP centers for oral care prior to this initiative.

Since this is a cost-effective mechanism it can be replicated/implemented in any of the countries, developing/developed with the help of decision makers. Proper support system with the need for such an initiative is the key to its success. It can even be replicated to be practiced in schools belonging to rural areas in some developing countries. Key issue here will be to customize the initiative to local needs and situations and effective implementation strategy.

Hence, we at SOHP strongly believe that this initiative is very much sustainable and can be replicated in any part of the world.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
Primary prevention is the key for the prevention of any chronic condition like dental caries. Starting prevention at a very early age to an individual and on time is a key factor to its success. These were the two most basic principles on which this initiative was based and which led to its success.
Providing our services within the schools to the children was another factor responsible to its success. This helped in saving time to all involved and hence increasing our coverage of children with prevention every year since 2006, key to the success of this initiative.
SOHP adopted best evidence-based methods which are effective in preventing tooth decay. Pit and Fissure Sealants reduce tooth decay by almost 60% after 5 years whereas Fluoride varnish applied on teeth reduced tooth decay by almost 40%. Hence adoption of proved and tested methods of prevention is another reason for the success of this initiative.
Increased awareness about the importance of oral health among parents and children led to increase in the number of positive consents received for prevention. This in turn increased our coverage in schools without clinics which was again a key factor in its success.
The very fact that this initiative is cost-effective compared to a normal dental clinic helped SOHP in convincing MOH to persist with it every year.
This initiative of using portable dental units for prevention of tooth decay was implemented in a very systematic manner with quantitative and qualitative measurements of the outcomes. This helped in measuring the success of this program. Also, the prevention carried out under this initiative was very aggressive and persistent since we had to combat school children the majority of whom were at a high risk for tooth decay.
The success of an initiative of this magnitude requires the support from all the personnel, decision makers, various departments, education teams, parents, teachers, media, etc and most importantly children. Hence team work is the most important key for its success.
SOHP plans to extend this initiative further until we have almost 50 operational mobile teams using Type A units and almost equal number of teams using Type B units. Also, plans are underway to introduce a prevention program to very young children in the age group of 1 to 4 years which would help us in controlling tooth decay in primary teeth before the child enters school.
The results ongoing National Oral Health Survey on School children which will be completed during December, 2012 should provide us more information regarding the changes that have been achieved through this initiative.

Contact Information

Institution Name:   School Oral Health Program, Kuwait-Forsyth
Institution Type:   Public-Private Partnership  
Contact Person:   Jitendra Ariga
Title:   Dr  
Telephone/ Fax:   +965 25753665/+965 25753664(Fax)
Institution's / Project's Website:   www.smile-mohkw.com
E-mail:   director@smilekw.com  
Address:   Post Box # 5338
Postal Code:   22064
City:   Salmiya
Country:   Kuwait

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