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 people who live in nursing homes in Sydling are considered as a vulnerable section of society that faces greater risks and worse oral health than average. Treatment alone will never successfully alleviate the causes of dental diseases. Health promotion offers the potential to tackle the underlining determinants of oral health thereby improve the oral health of this section in society (Daly et al, 2003). Therefore, there is a need for effective and affordable intervention for better oral health and quality of life, which are integrated into general health programmes. WHO had provided guidance on interventions design in 1998 which emphasised the following elements: they should be empowering, holistic, equitable, and sustainable and multi-strategy (Watt, 2005).
Stages in Planning an Oral Health Promotion Strategy: Planning Cycle
To promote oral health and reduce dental caries requires coordinated and planned approach. Planning involves several stages, which enable the health promoter to achieve a desired result as well as it direct the resources to where they will have the most impact (figure 1).
Assessing Needs
Assessing the oral health needs is an essential step in developing effective and sustainable interventions to promote oral health. A recent assessment of oral health needs of older people living in nine nursing homes in Sydling has highlighted a number of oral health problems:
- Untreated dental diseases such as dental caries, missing teeth, colossal wear of denture, loose dentures.
- Inadequate oral hygiene practices.
- Negative impact of poor oral condition on the quality of life by affecting their ability to communicate effectively, to eat, speak and carry out their daily activities.
- Limited knowledge of staff on oral care assessment or how to look after their resident’s mouth.
- Difficulty in accessing dental services when needed.
Goals and Action Plans
The overall aim of the programme is to promote oral health and improve quality of life among elderly people in nursing homes in Sydling over the two year plan. The Ottawa Charter was developed by the WHO as a framework for constructing a health promotion programme that addresses the underlying determinants of health. It suggests that the programme be built around the following five action areas. There are defined measurable goals in each action.
Creating a Supportive Environment
- Goal: facilitation of adequate and appropriate access to fluoride
There is evidence to show that fluoridated toothpaste and fluoridation of the water supply results in a significant reduction in root surface caries in older age (Steele & Walls, 1997). We should ensure that all nursing homes have adequate access to appropriate level of fluoride in tap water, as specified in drinking water guidelines. The main factor contributing to the decline in dental caries is fluoridated toothpaste (Sheiham, 1984). Therefore, free fluoridated toothpaste with electronic tooth brushes should be given to all residents.
- Goal: improve physical environments.
The physical environment and layout of nursing homes have a great impact on oral and general health of residents. Therefore, nursing homes should provide a clean and safe environment (Naidoo & Wills, 2000). All residents should have access to privacy for oral hygiene facilities. Taps should be suitably adapted for the individual residents’ needs. Besides, sanitary fittings should be fully accessible to disabled residents, and adequately illuminated. Additionally, there is a need to provide a room for on- site dental treatment in all nursing homes. Having areas where residents can sit in front of open windows or sit outside maximises the opportunities for older people to access vitamin D from exposure of the skin to sunlight (The Carolina Walker Trust, 1995). The quality of social interactions among residents, between staff and residents and between staff contributes to ethos or climate. There is substantial evidence that indicate that the extent to which social relation is strong and supportive is related to the health of individuals (Cassel, 1976).Therefore, there should be areas for social interaction.
Building healthy public policy
- Goal: provision of healthy food.
Poor oral status of institutionalised older people may contribute to eating problems, weight loss, dehydration and debility (Simons, 1999). Sheiham, et al. (1998) state that older people’s selection of their food depends on the numbers of teeth they have and the presence of dentures. They tend to choose softer and more easily chewed foods that are lower in fibre and less nutrient dense. The importance of the dental status in relation to the ability to eat certain foods is even more important in institutionalised people. Caterers should consider the dental barriers to eating essential foods. Whilst there is a little benefit in providing foods that cannot be eaten because of an impaired dentition, there is also a need to ensure that overall balance of the diet is not impaired because of the state of the dentition. It is recommended that in line with good health promotion, healthy eating choices are made available (Steele, 1989). The plan is to develop a catering policy in all residential homes in Sydling. Rather than focusing upon caries prevention, an alternative approach is the development of a holistic nutritional programme, which aims to improve the overall nutritional status of residents (Sheiham & Plamping, 1988). Chefs and caterers should have cooking classes and use the practical guidelines for the provision of food for older people in nursing homes as were published in eating well for older people (The Carolina Walker Trust, 1995). Additionally, these, nutritional guidelines are applied equally to older people with dementia. We should ensure that all residents should have the opportunity to enjoy eating more fruit, vegetables, starchy carbohydrates and less sugar, salt and fat (Chernoff, 2001).
- Goal: marking dentures.
Marking dentures has been well documented as a useful aid in the identification of misplaced dentures in nursing homes. Misplaced or mistaken dentures in nursing homes for the elderly can be a considerable problem. On this ground, denture identification policy is important (Raymond et al, 2007).
- Goal: reducing smoking rates.
Smoking is an aetiological factor associated with periodontal diseases and oral cancer. Therefore, there should be a policy to prevent smoking in all nursing homes. This smoking policy seeks to guarantee all residents the right to live in air free of tobacco smoke (Watt & Sheiham, 1998).
Developing personal skills
- Goal: Improve oral health knowledge and attitude and oral hygiene practices of all Residents and staff.
Oral health training programme for residents aiming at self-care capacity building of older people and enhance their knowledge and oral hygiene practices as well as dietary awareness in the context of healthy eating for oral and general health. The intervention consisted of sessions lasting approximately one hour, covering the role of plaque in oral disease and including demonstrations of cleaning techniques for dentures and natural teeth.
Plaque score among elderly people in institutions are much higher than among the free living people and root caries correspondingly high (Steele &Walls, 1997). Elderly occupants of nursing homes are often dependent on their carers to perform all their daily care due to physical or mental problems and thus carers play a pivotal role in dental diseases prevention (Simons et al. 2000). Approximately 54% of residents suffer from dementia which may influence self-care ability, requiring care needs to be met either partially or wholly by nurses and care staff. The staff in nursing homes didn’t receive any formal training in assessments of oral health or how to look after the residents’ mouths. The importance of a basic oral health assessment and of oral care by nursing staff has been reported by several authors (Griffiths & boyle, 1993). Evidence on the use of oral assessment screening tools showed that successful assessment of residents with and without dementia by nursing staff required appropriate staff training in association with a dental professional. The oral health assessment could be incorporated into a routine assessment by care staff. The action plan is to provide staff training focus on use of oral assessment screening tools, oral health issue, provision of oral hygiene care and organising dental appointment (Trenter & Creason, 1986). Caregivers demonstrated the practice of these techniques using a manikin head, models and other teaching aids. Training programmes should be based on scientific principles which stress the poor standards of oral hygiene can be a serious health threat. There is also a need to consider the longer-term format of training programmes for staff, with regular refresher courses being provided to ensure that improved oral health care is sustained. Such training could be achieved at a relatively low cost with use of dental hygienists and dental health educators (Steele & Walls, 1997).
Reorienting health services
- Goal: Improve access to dental services.
Improve access to dental services in terms of time, cost and distance to ensure that all residents can utilize the dental services. This can be done by providing routine and urgent dental care. Emergency dental care should be available within twenty-four hours with a clear referral for routine advice and treatment. Continuing dental care should be available for all residents. Moreover, all staff and managers should have access to information on General Dental Services, Community Dental Services and specialist Hospital Dental Services. Additionally, commission services which match the needs of all residents, for example, use the mobile dental units, extended opening hours, walk in clinic, routine free dental checkups and adopt NICE recall guidance (Guidelines for Oral Care, 2000).
- Goal Provision of preventive care programs for all residents
A range of additional agents are available which may make an important contribution to preventing dental diseases in dependent elderly people such as chlorhexidine mouthwash, saliva substitutes to reduce xerostomia and fluoride varnish programmes. Moreover, the dental team must be encouraged to adopt more preventive practices as outlined in delivering better oral health (Chalmers & Pearson, 2005).
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 oral health is important for several reasons such as provision of feedback for population, making best use of resources and improvement of health promotion practices. Whole range of key players including health commissioner, managers 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).
Data collection methods
It is essential that the evaluation method selected is appropriate to the nature of the intervention. In oral health promotion, quantitative methods have dominated. Both approaches are valuable and should be used when appropriate. A mix of qualitative and quantitative data will be used to undertake process and impact evaluation.
Process evaluation is used to assess the elements of programme development and deliver, that is, the quality, and reach of the programme. This type of evaluation will be during the entire life of the programme from planning through to the end of delivery. Table 1 outlines the appropriate methods to collect data to evaluate the process measure.
Table 1.Process evaluation of health promotion interventions
Table 2 is a modified model provides a theoretical framework for evaluation and describes a variety of evaluation measures:
Health promotion outcomes
These assess the immediate impact of any planned health promotion activities.
- Measures of health literacy assess older people’s knowledge, attitudes, and skills. It can be evaluated by comparing pre/post test survey to assess the changes one week after the workshop.
- Social and influence refers to any efforts to enhance the control of social groups over the determinants of health. This can be accessed through questionnaires given to careers to explore their opinions on oral health issues.
- Healthy public policy practices are an important means of creating an environment that is supportive to health. Copies of policies collected from nursing homes to see how many nursing homes implement food, fluoridation, denture identification and smoking policy
Intermediate health outcomes
- At the very essence of health promotion is the aim of increasing individuals and communities’ control over the determinants of health (WHO, 1986). Intermediate health outcomes are a means of assessing the modifiable determinants of health.
- Healthy lifestyles refer to health related behaviours such as eating patterns, tobacco use and exercise routines, all will be assessed by interviews with residents after 12 months. Provision of preventive care and access to and appropriateness of health services also determine health status and are included in effective health services. This is assessed by face-to-face interviews with managers.
- The nature of the physical and social environment is a key determinant of health. Measures of a healthy environment may include features of the physical environment, and social conditions, availability of healthy food choices and restricted access to tobacco. The data will be collected from focus groups with residents and questionnaires to all managers.
Health and social outcome
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 health promotion evaluation in this model. Social outcome measures include quality of life indicators. After 24 months from intervention, (OHQoL-UK) questionnaire will be given to all residents to assess the extent to which oral health affect not only physical functioning and pain, but broader constructs such as psycho-social functioning and life satisfaction.