3.1. Consent Status
In Port Augusta in 2000, there were 2839 preschool and primary school students eligible for the SDS. There were a total of 706 Aboriginal children enrolled in schools in Port Augusta, of which 537 (76%) were preschool and primary school students, and 169 (24%) were high school students. Of the Aboriginal children in Port Augusta, 316 (58.8%) of preschool and primary school children had an active consent status compared with 60 (35.5%) of high school students (). The overall consent rate for Aboriginal children in Port Augusta, combining preschool, primary school, and high school children in Port Augusta was 53.0%. The active consent rate for non-Aboriginal preschool and primary school children in Port Augusta was 85.7% (). These figures compare with a reported active consent status of 76.1% for preschool and primary school students and 49.4% for high school students for SA overall in 2000 [11
]. The average combined (Aboriginal and non-Aboriginal) participation rate for preschool and primary school students in 2000 for Port Augusta was 77.0%.
Consent rates for Aboriginal children in Port Augusta with comparisons to state-wide data.
3.2. Factors Influencing Participation
Informal interviews with SDS and PWHS staff identified a number of key issues influencing participation rates. These included a high rate of failure to attend appointments, attendance patterns for relief of pain rather than follow-up care, difficulty contacting parents and guardians, and difficulty communicating effectively with parents and guardians (). Pika Wiya Health Service staff identified additional issues including difficulties with transport, not receiving appointment cards, lack of knowledge of the importance of dental care, and a lack of Aboriginal staff in the dental service.
Key issues and challenges identified through informal interviews.
3.3. Framework for the Delivery of Aboriginal Children's Dental Program
The commitment and shared responsibility of key stakeholders were considered crucial to successful implementation of the Program. The South Australian Dental Service funded the clinical service components, including staffing of a dental therapist and dental assistant, consumables, and maintenance of clinical equipment. The PWHS provided funding for an Aboriginal Primary Health Care Worker and transport officer, provided office space, nonclinical equipment, and all on-costs. The Spencer Gulf Rural Health School provided scholarship funds for a postgraduate dentist already working with the adult service to manage the Program, provide clinical support and plan and deliver health promotion components. The University of Adelaide School of Dentistry continued to provide an advisory role, support and mentoring for the postgraduate dentist, and provided an avenue for development of future research projects.
A service model that addressed the key challenges and barriers identified was established to meet the goal and objectives of the project. The service model was reviewed regularly with dental service staff, staff involved in other programs within PWHS, Aboriginal Education Workers, staff at the schools, and PWHS and SA Dental Service management. Modifications to the model were implemented as potential improvements were identified. In particular, the service was to be given the freedom of adapting to feedback from the community it was designed to serve.
Whilst the model planned to focus on primary health care, implementing early intervention and health promotion strategies, it was acknowledged by stakeholders that this would take time to achieve, and the prime focus was therefore to be a service model that encouraged and facilitated participation by the local Aboriginal community.
The overall goal of the ACDP was to improve the oral health of Aboriginal children in Port Augusta. Specific objectives included (1) to provide a culturally friendly children's dental service, (2) to ensure that all school-age Aboriginal children have a comprehensive examination, (3) to ensure each child completes the course of treatment arising from that examination, (4) to establish and manage a system of recalls, (5) to provide an emergency service, (6) to ensure a strong focus on community health promotion, and (7) to increase the number of Aboriginal children accessing routine and preventative dental services.
Stakeholders agreed to implement a School Dental Program from PWHS (the ACDP) as a pilot project in the first instance. Commencing in February 2002, the ACDP took the following form for the initial 12 months
- Operated from within the existing PWHS Dental Clinic
- Operated one day each week
- Utilised a South Australian Dental Service-employed dental therapist and dental assistant
- An Aboriginal Health Worker organised patient appointments and liaison
- The service was supported by a dentist who managed Program implementation and provided clinical support
- Key service statistics were collected through routine case notes and data entry
- School-based health promotion Programs were instituted and conducted by the Aboriginal Health Worker and dentist together with other clinic staff as appropriate.
Key differences between the ACDP and the existing mainstream SDS are described in .
Key differences between ACDP and the mainstream SDS.
3.4. Health Promotion
Health Promotion activities in the first 12 months of the Program included the Aboriginal Health Worker and dentist providing an education session for all classes in five of the six Port Augusta primary schools and the kindergarten with the greatest number of Aboriginal enrolments. School-based health education sessions focussed on providing health information for children and staff, as well as promoting the service and ensuring children were familiar with staff and the concept of dental visits and treatment. Staff also participated in broader health promotion activities and community events.
From 2003, the Aboriginal Health Worker and dentist worked with the dietitian at PWHS to deliver joint health promotion activities, such as school-based activities, demonstrations of healthy cooking and snack alternatives, and involvement in community health events. In 2004, four dental students from the University of Adelaide School of Dentistry helped to deliver a workshop for Aboriginal Health Workers on oral health. In addition, they developed a series of simple information sheets for Aboriginal Health Workers and patients on the importance of oral health for pregnant women, people with diabetes, and people with heart disease. In 2005, six dental students were also involved with developing health promotion resources aimed at different age groups. Further health promotion programs have been developed through research partnerships with the University of Adelaide School of Dentistry but are beyond the scope of this paper.
3.5. Program Adaptation
Consistent with the aim of adapting to community needs, the Program continued to evolve. Enrolment of children into the SDS or the Program normally occurs by the parent once information about dental services is provided by the School. In order to assist in enrolment of Aboriginal children in the SDS or the Program, contact was maintained with Schools. Strategies were explored to ensure that privacy was maintained whilst acknowledging the need to address and support the particular health needs of some students and families. For example, a school representative visited the clinic and worked with the Aboriginal Health Worker to identify students who needed to be contacted, without either the school or clinic releasing students' details.
Due to funding problems, there were periods where the ACDP needed to function without an Aboriginal Health Worker. The loss of this employee, as well as transport staff accepting more permanent positions elsewhere, contributed to high staff turnover for the program. As the Aboriginal Health Worker was the key link with the community, other ACDP staff needed to take on additional roles and attempt to fill aspects of the position in their absence. This proved difficult, stretching staff already functioning in demanding roles. Staff also believed that the lack of continuity of an Aboriginal Health Worker with the program restricted the development and growth of the ACDP, potentially affecting enrolment and participation rates as well as service productivity.
After a full examination and determination of an appropriate treatment plan for the patient, an appropriate interval for a recall appointment is determined based on an assessment of probable disease risk. In late 2004 and 2005, it was noted that the planned appointing of recalls was behind schedule, thought to be as a result of the high treatment needs of individual patients and the challenges with maintaining anticipated productivity whilst managing failed appointments. To ensure that the recall times did not continue to extend, the dental therapist began making appointments for clients on the current recall list at the scheduled time, whilst also trying to clear the backlog of recall appointments. The dental therapists reported that patients recalled at the scheduled time seemed to have fewer treatment needs than when first entering the service and fewer needs than those who had waited longer for the recall visit.
3.6. Participation Rate
The establishment of the ACDP saw an increase in the overall participation rates of Aboriginal children in dental services in Port Augusta as well as a shift in the distribution of enrolment from the mainstream SDS to the ACDP offered at PWHS ().
The number of Aboriginal children enrolled in the ACDP at the PWHS in October 2005 (after approximately 3 and a half years of operation) was 679, and the number of children on the recall list was 438. This indicates that 64.5% of the children attending for comprehensive examination and treatment planning were then placed on the appropriate recall list (). The number of Aboriginal children enrolled in the Australian Dental Service mainstream SDS was 137, with 31 children enrolled in both the mainstream SDS and the ACDP, giving a total of 785 Aboriginal children enrolled in either the mainstream SDS or ACDP in October 2005. The proportion of children enrolled and on recall was 544 (69.3%). This figure has been used as a conservative estimate of the participation rate in dental programs, the closest in definition to the “active consent rate” criterion used with the mainstream SDS, giving an increase in participation rates from 53% in 2002 to 70% in 2005.
Regular cross-checking of names of children enrolled in the mainstream SDS ensured that duplication between the dental programs was minimised. Once it was confirmed which clinic a family wished to attend, the child's name was removed from the alternative clinic's contact list.
3.7. Service Statistics
From February 2001 to June 2005, a total of 591 clients were seen over 2074 visits (). Participation rates steadily increased over the first year of operation, stabilising after 24 months. Given early demand for appointments and procedural services, it became necessary for the clinic to open an additional day each week, opening 2 days per week from late January 2003.
From February to June 2002, 119 new patients had a full examination, including a treatment plan (). Following the increase in the number of operating days in January 2003, the number of new patients having a full dental examination decreased steadily, indicating that over time the backlog of clients was decreasing. However, as a direct consequence, the number of patients attending for recall examinations steadily increased, reflecting the increase in patients who completed their initial course of treatment and were attending for a “check-up” or recall examination.
The number of emergency examinations remained reasonably constant, averaging 31 emergency examinations in each half yearly period (). Emergency examinations indicate that a patient attended for a specific concern only and may include patients new to the service, patients who attend outside of their planned recall with an urgent problem, or patients not normally enrolled in the service. The number of extractions remained reasonably constant throughout the operation of the service, averaging 20 extractions in each half yearly period (). The number of restorative procedures performed increased initially and then plateaued, again demonstrating clearing of a backlog of required procedures. The number of restorations placed in each period levelled off at a mean of 162 from January 2003 onwards.
The number of preventative services provided in each six-month period increased from 85 in Jul-Dec 2002 to 271 in Jul-Dec 2003, and 228 in Jan-Jun 2005 (). The mix of preventative services demonstrated a hump pattern, changing throughout the service's operation. Fluoride treatments increased steadily whilst the number of cleaning services remained constant from Feb 2002. While oral hygiene instruction services saw a dramatic increase from Jun-Jul 2002 to Jul-Dec 2003, the number of oral hygiene instruction services remained stable outside that period. The number of fissure sealants, placed to prevent dental caries in the pits and fissures of teeth, mimicked the pattern of oral hygiene instruction from Jul 2002 to Dec 2004.
The number of cancelled and failed appointments increased in the first four periods, peaking in the period Jul-Dec 2003, with a total of 281 missed appointments (). Failure to attend appointments accounted for the majority of missed appointments across all but the first period.