Dental caries is a serious problem for Australian Aboriginal children [1]. For example, Aboriginal children living in New South Wales (NSW) experience on average 2.64 decayed, missing or filled teeth (dmft/DMFT) due to dental caries. This is near double the dmft/DMFT rate of 1.54, experienced by non-Aboriginal children in NSW [2]. When left untreated, dental caries can cause severe pain, and negatively impact a child’s quality of life, ability to concentrate at school, and capacity to eat, speak and socialize without embarrassment [3].
Improving the oral health of Aboriginal children is a priority in the Oral Health 2020: A Strategic Framework for Dental Health in NSW [4], and the NSW Aboriginal Oral Health Plan [5]. It is essential that strategies aimed at improving the oral health of Aboriginal children are sustainable, supported by the local Aboriginal community and culturally competent [6].
Culturally competent health promotion programs for Aboriginal people should be developed in consultation with Aboriginal communities and designed to meet the needs of specific communities [5]. Additionally, they should be culturally and linguistically appropriate, evidence-based, sustainable, implemented in collaboration with communities and evaluated [7]. In rural and remote communities, programs that solely rely on the input from dental professionals are often not sustainable given the general shortage of qualified professionals [4]. Therefore, prevention programs that can be delivered by the local Aboriginal community are likely to be more sustainable and suitable for the needs of that population.
In 2013, Aboriginal Elders in Central Northern NSW, identified three Aboriginal communities that had extremely limited access to dental services and needed preventive oral health care programs. Subsequently, the Poche Centre for Indigenous Health and the Centre for Oral Health Strategy were invited into these communities to work in partnership with the local Aboriginal community to introduce sustainable dental services and preventive oral health care programs for Aboriginal people in the region [8] In 2014, a community-led oral health service was established, which provides comprehensive dental treatment for Aboriginal people in Central Northern NSW. The service operates using clinicians who have relocated to the region and local Aboriginal people who have been trained and employed as dental assistants. Portable dental equipment is used to provide dental treatment to Aboriginal children and adults from schools and local community health centres. The local Aboriginal community still however, maintained the need for preventive oral health care programs to be implemented alongside dental treatment provided in schools and community health centres.
In response to the community’s request for preventive oral health care programs, a three-stage plan based on the Precede-Proceed model of health program planning was used to develop a sustainable, community-led preventive oral health program (Fig. 1).
The Precede-Proceed model was used as it is a popular planning tool for population health programs [9]. It consists of a series of phases to assist researchers plan, design, implement and evaluate health programs. The first set of phases (PRECEDE) includes planned assessments to inform the design of the health program. The second set of phases (PROCEED) involves implementing a health program based on information learnt from the PRECEDE phases [10].
Guided by the Precede-Proceed model, Stage 1 included an epidemiological assessment of all Aboriginal children aged 5–12 years enrolled in local schools as well as an educational and ecological assessment of the community to determine predisposing risk factors and reinforcing and enabling factors to inform a targeted oral health program. The number of decayed, missing and filled teeth were recorded as well as baseline oral health knowledge and oral hygiene practices of children, parents/guardians, school staff and health workers.
The baseline data collected as part of Stage 1 data provided valuable planning information. The majority of children (87.5%) had untreated dental caries. The mean number of decayed primary teeth (dt) was 4.1 and the mean number of decayed permanent teeth (DT) was 0.7, indicating a clear need for dental treatment and education to prevent dental disease [11].
Ecological and educational assessment of the community identified four predisposing risk factors associated with an increased risk of developing dental caries:
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Low levels of tooth brush ownership
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Infrequent daily toothbrushing with a fluoride toothpaste
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Frequent sugar consumption
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High intake of sugar-sweetened beverages rather than drinking tap water
Based on the risk factors identified, the following oral health promotion strategies for Aboriginal children living in Central Northern NSW were developed, namely: increasing fluoride use through daily toothbrushing; ensuring safe and refreshing tap water is accessible to encourage the consumption of water rather sugar sweetened beverages; providing culturally competent oral health and nutrition education; and providing training programs to build capacity of the local Aboriginal community and existing health workforce to ensure oral health promotion is led and supported by the community.
The results of Stage 1 and proposed oral health promotion strategies were presented in a leaflet and also verbally reported back to the local Aboriginal people at an open community forum (locally known as a community ‘yarn up’) which is held to discuss local issues and events. The ‘yarn up’ included local Aboriginal Elders, teachers and school principals from the three local schools and representatives from the Poche Centre for Indigenous Health. The strategies were well-received at the ‘yarn up’ and members verbally agreed to the development of an oral health promotion program to be implemented in each of the schools in the three communities; which was later formalised in writing. This led to Stage 2 and thus the ‘implementation phase’ of the Precede-Proceed model.
Stage 2 involved developing a school-based oral health promotion program based on the findings of Stage 1. The program includes:
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Daily in-school toothbrushing
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Distribution of free fluoride toothpaste and toothbrushes to children and families
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In-school and community dental health education
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Installation of refrigerated and chilled water fountains to supply a school water bottle program
The four components are based on existing programs which have shown to be effective in other Aboriginal communities [6, 12], and utilising high quality systematic reviews [13]. This study protocol describes the components of the proposed school-based program and evaluation protocol to determine the feasibility, efficiency and effectiveness of the strategies to control dental caries in Aboriginal children living in rural and remote communities in NSW.
The aim of the program is to improve the oral health of Aboriginal children by promoting daily toothbrushing using fluoride toothpaste, increasing oral health knowledge and encouraging the consumption of water to reduce the reliance on sugar-sweetened beverages.
Stage 3 will pilot the proposed program for 12 months in three schools in Central Northern NSW that enroll a high proportion of Aboriginal children. The process evaluation to be undertaken at the completion of the pilot, is based on the Precede-Proceed model for process evaluation (Phase 6) and will determine the program’s feasibility, efficiency, effectiveness and overall satisfaction of the participating communities.