Introduction
The proportion of older people continues to grow worldwide, especially in developing countries. This, along with an increase in the prevalence of oral diseases and non-communicable diseases, will significantly challenge health and social policy planners (Petersen and Yamamoto, 2005). Oral diseases and impairments are most commonly experienced among older people with special needs, that requires long term care at home or in institutions. Studies in many countries have demonstrated that institutionalised elderly people have significant dental needs experience and greater barriers to receiving dental care compared with older people who live independently (Drake, 1991). Elderly who live in nursing homes in Regbakestain are considered as vulnerable section of society that faces greater risks and worse oral health than average. Therefore, adequate dental care service is required urgently to suit the needs of these residents.
There are 9 nursing homes In Regbakestain and seven of these are registered as government nursing homes, while two are registered as privately run nursing homes. The number of registered residents is 430 and the mean age of residents is approximately 82 years. Residents in nursing homes experience a number of oral health problems. These include access to health care services, denture problem, decay, dry mouth and burning mouth (Table 1&2). Furthermore, the staff in this area did not receive any formal training in assessment of oral health or how to take care of these complications. Regarding general health, there are 54% of residents suffering from dementia. Currently the homes do not have a dentist or other type of oral health worker with specific responsibility for treating the residents.
Clinical dental status
Of the 430 residents in the nine nursing homes, 50 residents were not approached because they were too fragile or agitated. An additional 80 residents refused participation in the survey. A total of 300 residents participated in the survey. Clinical examination was conducted for 297 residents because 3 participants refused the clinical examination. The results from the clinical examination show that a high proportion of dentate residents were affected by tooth (43.8%) and root caries (63.3%). Moreover, more than one in four dentate residents had tooth mobility.
For edentate residents, one of the main problems was occlusal wear with 57% of dentures showing some evidence of this condition. Nearly one quarter of dentures (23.4%) were assessed to have inadequate denture occlution relationship and 20.3% had denture stomatitis or an ulcer. In relation to the interview, 107 participants were excluded due to unsatisfactory cognitive ability. Another 8 participants refused participation in the interview or did not speak English. Therefore, the interview was done on 185. An approximate 66.7% of dentate and 43% of edentate residents reported having oral health problems. Dry mouth and cracked/sore lips were the most commonly reported problems.
Situation analysis
The analysis of the main Strength, Weaknesses, Opportunities and Threats (SWOT)
Strengths
The Ministry of health has set aside the sum of €300,000 to provide clinical treatment for this neglected group of people. This sum is available for one year and will cover the staffing cost and any treatment provided by private dentist.
Weakness
- No dentist or other type of oral health worker with specific responsibility for treating the residents
- No standardised guidelines
- Poor data collection and health information system
- Problem with access to dental service
- No standardised clinical guidelines
Opportunity
- Ranges of governmental oral health personnel and besides general dental practitioner are available.
- A variety of option for providing dental care for this population is available (room in nursing homes, mobile clinic or local dental practices).
- Government commitment to supply the clinical facilities, materials and equipment.
Threats
- More than half of the residents suffer from dementia.
- Limited timeframe; all treatment should be completed in one year.
- 133 incidences of missing data from the survey which may make the survey fail to reflect all possibilities.
Delivery of Dental Services
A number of factors influence the selection of an appropriate site for treatment of institutionalized elderly people with dental problems. These include cost, manpower and availability of domiciliary equipment, availability and access to mobile dental units, time and experience of the dental team. Therefore, appropriate site and modality of dental service provision is needed to meet the needs of the residents.
The evidence would suggest that those people with dementia are better treated in familiar surroundings to reduce anxiety and confusion and to increase compliance (Dougall & Fiske, 2008). In nine nursing homes more than half of the residents suffer from dementia and 50 residents fragile therefore all examination and treatment will be done in resident’s room for highly dependent residents. Domiciliary care will be provided in the available rooms in nursing homes by using portable equipment or mobile dental units. On the other hand, independent residents who have no problem to walk to mobile dental clinic will have their treatment there.
Appropriate mix of dental team skill is crucial to Maximum use of the potential dental workforce to work within time and budget provided as follows:
Evaluation
Evaluation has been defined as the process of assessing what has been achieved, whether specific goals and targets have been met and how it has been achieved (Ewles and Simnett, 1999). Prior to the delivery and implementation of any intervention, the evaluation should be considered and planned. The evaluation of intervention is important for several reasons such as make best use of resources and improve health care practices. Whole range of key players including health commissioner, mangers and community representatives can become involved. The participation of these groups can increase the relevance and credibility of the evaluation results. Quality evaluation requires adequate resources and personnel with the necessary skills and experience (WHO, 1998). Under resourced evaluation limits the potential for demonstrating the value of interventions and sharing good practice. The WHO has recommended that at least 10% of the budgets for interventions should be directed to their evaluation (WHO, 1998).
Process Evaluation
Process evaluation examines the extent to which the programme is delivered as designed. In general, process evaluation employs a wide range of qualitative methods, for example, interview, diaries, observations and content analysis of documents. These methods tell us a great deal about particular programme and the factors leading to its success or failure. Process evaluation will address the following question
- How well the programme implemented?
- Did the intervention reach all residents?
- What proportion of the residents received the intervention?
- Was the intervention acceptable?
Outcome Evaluation
In addition to the conventional disease and health status measures that are used in the assessment of treatment interventions, social outcomes are also included as appropriate outcomes for evaluation in this planning. Social outcome measures include quality of life indicators. To measure the effectiveness of the aim and intervention we need to examine the improvement in oral health status. To measure the access and efficiency we need to examine increasing the numbers of activities against resources with improvement in oral health conditions. To measure the equity and relevance we need to have equal provision for equal need.
Conclusion
People in resident care in Regbakestain have an equal right to good oral health as people residing in the community. Therefore, effective action is urgently needed to tackle oral diseases among this vulnerable group. The most effective interventions focus on broader determinants of oral health through upstream but due to limited time, this plan will focus on clinical treatment. However, this policy has limitations due to the shortage of data available (133 missing data) and limited time. Sustainable positive changes in oral health require actions to address the underlying determinants of oral diseases (Watt, 2007). Due to the limitation of time, this policy concern oral health care services.