This is a guest post that has been compiled and edited by Andrew Paterson. It describes a recently completed pilot programme undertaken jointly by Bridge2Aid and Smileawi in partnership with Martha Chipanda, the Oral Health Coordinator at the Malawi Government Ministry of Health. The project aligns closely with the disease prevention component of Malawi’s new National Oral Health Policy, due to be launched on 14th April 2022. The pilot programme was funded by Scottish Government through the MalDent Project, and supports the workstream on communicating messages which promote good oral health.
Contributors: Martha Chipanda, Andrew Paterson, Shaenna Loughnane, Nigel Milne, Victoria Milne, Jeremy Bagg
One of the key challenges in African healthcare is providing appropriate coverage for those living in remote and rural areas, which includes 60-80% of the population in countries like Malawi. These areas are underserved by both health services and health promotion. With the inclusion of oral health into the Malawi Government’s essential package of healthcare, the recent World Health Assembly statements on the importance of oral health, the MalDent Project and the new Malawi Bachelor of Dental Surgery degree programme there is significant momentum to address rural oral health in Malawi.
In 2020-2021, funded by a Scottish Government grant to Smileawi, Northern Malawi dental therapists were upskilled in the relationships between oral health and non-communicable diseases and taught skills to teach rural community volunteers to cascade-train key oral health messages within their remote communities. This course was delivered remotely using tablet computers (mOral Health) and coordinated locally. It was a collaborative effort of the NGOs Bridge2Aid and Smileawi, ProDentalCPD, the Dental Association of Malawi, The Ministry of Health of Malawi, the MalDent Project and the Universities of Glasgow and Dundee.
The next stage was for the therapists themselves to design a programme best suited to training community volunteers who could then cascade the oral health messages widely in their own remote communities. This was resourced by the Scottish Government funded MalDent Project and involved collaboration between Bridge2Aid, Smileawi, the Dental Association of Malawi, The Ministry of Health of Malawi, the Red Cross, the MalDent Project, the University of Glasgow, and the Kamuzu University of Health Sciences. The therapists were coordinated, supported, and managed by Dr Martha Chipanda (National Oral Health Coordinator) and production of teaching materials was facilitated, supported, and edited by Bridge2Aid and Smileawi volunteers.
The area selected for the first cascade training was Mzimba North in Northern Region Malawi. This is the largest District in Malawi with a population of over 600,000 people predominantly based rurally with agriculture being the main work in the area. Crucially some of the therapists who had received our training in 2020-2021 work in Mzimba North. There are many barriers in Mzimba North to access rural areas as the road system is primarily unpaved and the main form of transport is bicycle. Public transport is infrequent and often fails to predictably reach destinations. Many areas are inaccessible in the rainy season. Having well trained oral health promoters available locally is the key to disseminating important oral health messages in this area.
The therapists delivered the training they had designed to Red Cross volunteers from many parts of Mzimba North in a central location over two days, which included empowering the volunteers to present the newly learned key oral health messages. The volunteers received teaching aids to use in their communities, being an oral health flip chart in the predominant local language of the area, Tumbuka and a tooth model and brush to demonstrate effective toothbrushing techniques.
Here are the reflections of some of the key stakeholders in this part of the project:
Martha Chipanda (National Oral Health Coordinator, Malawi):
Training Oral Health Promoters is one of the ways to implement Malawi’s National Oral Health Policy. This pilot programme was focused on the promotion of oral health and prevention of common oral diseases. It tested the concept of cascade training using dental therapists to facilitate the training of non-health volunteers who would have a pivotal role in spreading oral health messages in their communities.
The Smile North therapists were extremely well organised which was important to the smooth running of the programme. Identification of volunteers was important. We targeted volunteers with the help of the Malawi Red Cross Society which enabled coverage of large parts of Mzimba North.
The volunteers were very excited and eager to learn. They actively participated in the programme and showed by their presentations that they were competent to deliver important oral health messages. At the end of the two days ten were successfully trained and hopefully they will play an important role in local oral health promotion. A certificate of attendance was given to the participants.
Feedback from the training therapists has been very positive:
“The programme is good for oral health promotion. The advantage is that it targets everybody, the rural, urban, and semi-urban population. But it is most advantageous to the rural population where oral health information is difficult to access”
“The programme is a mindset changer and a primary preventive measure that is bound to reduce the number of dental and oral conditions in most rural parts of the District. The programme is already gaining publicity within Mzimba North rural areas”
Following the programme, the therapists have also suggested modifications that may improve the programme such as providing some phone support for the community volunteers so that questions can be answered, additional support provided for challenges that may arise and to update the trained volunteers on changing oral health priorities.
This long-awaited programme has given hope and light to Oral Health Promotion and Prevention in the Northern Region. It is the hope that this can be similarly rolled out to other regions in Malawi.
Thumbs up to Bridge2Aid, Smileawi, the MalDent Project, the Malawi Government, the Scottish Government, the Dental Association of Malawi, the University of Glasgow, and the Kamuzu University of Health Sciences who all collaborated to bring about a successful course. There were many others who contributed to the delivery of this course who are too numerous to mention but their input is much appreciated.
Andrew Paterson (University of Glasgow & Bridge2Aid Trustee):
Being involved in the initial training programme to upskill the dental therapists and to teach them teaching skills and then to be further involved in a Malawian led and developed oral health cascade training programme has been, and continues to, be an uplifting experience.
A legion of problems was overcome by close collaboration and teamwork. One of the unexpected benefits of the programme has been that when the stakeholders involved in oral health in Malawi work cohesively and closely together the benefits of those relationships is good for the improvement of oral health.
The decision to provide teaching aids for the community workers in the local language of the area, Tumbuka, makes this form of cascade training particularly relevant and culturally appropriate to the needs of rural communities and will hopefully translate into improved oral health literacy in the area. This fits with the WHO principle of not leaving anyone behind by giving all the opportunity to receive appropriate health messages in a format they understand. That said there were a few uneasy moments after this decision with the realisation that our combined knowledge of Tumbuka amounted to five words. Nevertheless, good communication and a ‘never say never’ problem-solving attitude from all collaborators involved meant the end goal was achieved.
This model of cascade training has benefits not just for oral health but for general health too. The messages speak to the prevention of NCD’s as part of the Sustainable Development Goals agenda. Take for example the messaging around quitting smoking. This messaging may impact on the many adverse effects of smoking more generally such as cancer and heart disease. In rural areas where general health promotion is sparse, oral health promotion offers significant benefits to general health.
This programme is a first step to cascade training for oral health in remote and rural Malawi. Much reflection is required on the lessons learned, problems solved, barriers and benefits of the programme and then it can hopefully be expanded into other Malawian regions with teaching materials in languages like Chichewa to remain relevant to specific localities. This training model may have potential for use in the wider Sub-saharan Africa region but there are many distinct cultural groups and what works for one area may not work for another, so if it were to be used widely then local oversight and collaboration will be imperative to remain culturally appropriate.
Shaenna Loughnane (CEO of Bridge2Aid):
It was fantastic to see the online training course created and delivered last year to the Dental Therapists based in Northern Malawi. However, this course was never designed to stand alone, and was co-created by a partnership of organisations and people passionate about making a real impact on the oral health of remote and rural communities in Malawi.
It has been great for Bridge2Aid to continue to work with similar partners to plan, create and deliver the second part of the programme – training Oral Health Promoters to work in their own communities to prevent oral disease and to share knowledge and behaviours that will have a huge impact on community health.
“Localise”, “capacity building” and “community-led development” are buzzwords in international development and have been around for a few years now. The concepts and values behind these buzz words, and other words such as “partnership”, “prevention” and “power-shift” are at the heart of the recent changes in strategy and programme focus at Bridge2Aid.
However, it is important that we don’t just pay lip-service to these concepts but embed them in all that we do. I truly believe that this programme embodies all these core values and is a real demonstration of what can be achieved if you work together, and ensure your project is led, managed, and delivered locally. It embodies the principles of building capacity for oral health education and aims to continue to spread important oral health messages to the remote and rural communities that so desperately need them.
We now need to ensure that we fully evaluate the programme, and the effect it has on oral health literacy and behaviours in the communities in which these volunteers work to ensure we are having the impact that was intended. This will allow for learning to take place to further develop the programme.
Nigel & Vicky Milne (Founders of Smileawi):
Smileawi has been enormously proud to be involved in this great project. When we first visited Malawi 10 years ago, we had no doubt that any significant improvements in oral health services would need to come from a governmental level and that seemed an impossible dream all those years ago. However, with the MalDent Project and all its different strands we are starting to see positive changes and not least with our friends and colleagues in Smile North. In 2020-2021 with a Scottish Government small grant Smileawi was able to produce and deliver the Oral Health Course to twenty-four dental therapists along with partners Bridge2Aid, the Dental Association of Malawi and Prodental CPD. The collaboration between these different organisations was highly successful and the course was very well received with positive feedback from all the participants.
“I have enjoyed very much the presentations and the knowledge I gained will help to improve oral health service delivery in the community”
“It was well organised and has really improved my teaching skills in imparting oral health messages to different groups of people”
The MalDent Project then stepped in to fund the next part of the process and we watched from afar as the team in Malawi led by Dr Martha Chipanda brought together six dental therapists and ten volunteers. The dental therapists then spent a couple of days teaching the volunteers basic but vital oral health messages and how to best pass these messages on to their communities. The challenges thrown up were mostly to do with financial and physical logistics and it was frustrating not to be there to help. We feel that the autonomy this has brought to this group of dental professionals can be seen as a triumph and our feeling is that they will grow in strength and conviction and with their voices being heard and the momentum they have achieved everything will continue to move in the right direction for oral health services in Malawi.
Jeremy Bagg (MalDent Project & University of Glasgow):
One of the great strengths of the Scottish Government-funded MalDent Project has been the extensive network of partnerships and collaborations it has generated. In retrospect, when the grant application was written, we did not have a full understanding of the scope and scale of what we were proposing. If it hadn’t been for our wonderful team of partners, we’d be way behind by now!
This proof-of-concept programme, examining the effectiveness of training dental therapists to deliver education on oral health to community workers, who can then cascade these messages to the population at large, is a perfect example of our joint working. Smileawi gained a small initial grant which supported work with Bridge2Aid, ProDental CPD and the Dental Association of Malawi to develop e-learning materials for a group of dental therapists in Northern Malawi. These therapists completed the online programme via devices and data purchased with the grant and have now delivered training to community workers (with assistance of the Malawian Red Cross), who in turn have gained experience of training others.
This oral health promotion programme directly supports the key plank of the new National Oral Health Policy (also developed as part of the MalDent Project), which is the importance of a preventive, as opposed to curative, approach to oral and dental disease in Malawi. As we move into the policy implementation phase, the timing is perfect.
On behalf of all at the Kamuzu University of Health Sciences and the University of Glasgow with responsibility for delivering the objectives of the MalDent Project, can I offer a massive vote of thanks to all partners involved. Yewo! Zikomo!