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Survey findings on changes in community attitudes to Infant Oral Mutilation following Bridge2Aid’s 2nd training programme in Tanzania – November 2022

Introduction

Infant Oral Mutilation happens to around 2.5 million children each year in East Africa. It is a dangerous and sometimes fatal practice where developing teeth are gouged out of the gums of small children using unsterilised, sharpened bicycle spokes. This practice is dangerous and sometimes deadly.

There is very little knowledge around oral health in rural east Africa. If infants suffer from sickness or diarrhoea when they are developing their first set of teeth, traditional healers often diagnose the growing teeth as the cause of the illness. They call this condition ‘plastic teeth’. The ‘treatment’ is to remove the growing canine teeth without the use of anaesthetic – and usually with unsterilised, improvised implements. This is extremely painful, dangerous and can be fatal.

Bridge2Aid (B2A) is currently implementing an Infant Oral Mutilation (IOM) awareness training programme in regions of Tanzania where Infant Oral Mutilation is practiced. It is crucial that we raise awareness of this through community engagement programmes to ensure IOM ceases to be a form of supposed treatment for common childhood symptoms of other diseases (malaria, food poisoning, infections etc).

The training was developed by Bridge2Aid and Dr Nila Jackson. The training workshops are being implemented by our local dental partner, the Sibaba Dental Clinic, led by Dr Jackson and a pilot study began in February with training delivered to 512 community participants in the Tarime District (Mara Region) in February 2022. With the support of the Chief Dental Officer, Dr Baraka Nzobo, we continued with a second, larger workshop in the Kyerwa District (Kagera Region) in May 2022, training a total of 834 people from across the local community.

Prior to our training, we survey women who attended local maternal healthcare clinics to assess the level of awareness of the myth of ‘plastic teeth’ and their perception of the dangers or benefits of IOM as a treatment. Then six months after the training is carried out, we return to health centres in the same areas and carry out identical surveys to gauge the effects that the training had in changing attitudes.

The results from the first survey in Tarime (taken in August 2022) were very positive, showing that there had been a shift in attitudes among the local population away from the myth of ‘plastic teeth’ and the use of IOM as a treatment. The post-training survey in Kyerwa took place between 15th & 23rd November and the comparative results with the pre-survey undertaken in May 2022 are summarised in this report.

Key Findings

In May 2022, prior to the training in Kyerwa, the team surveyed 1,083 women attending maternal clinics to assess the level of awareness of IOM and ‘plastic teeth’. This was carried out by using pre-structured self-administered questionnaires. The 6-month post-survey in November surveyed 1,012 women in Kyerwa and the results show a shift in community attitudes in understanding the dangers of the myth of ‘plastic teeth’ and IOM, that are consistent with what we saw in the Tarime results of the pilot programme. During the post-training survey, Dr Nila Jackson interviewed some of the Community Health Workers who attended May’s training to ask them if they had noticed a change in attitudes.

88% of those surveyed in May said that they believed that ‘plastic teeth’ caused illness and required treatment. Our post-training survey in November, with a similar sample size, found that this number had shown a gradual fall to 75%, similar to that of the pilot survey (see Figure 1).

The link between childhood illness and the myth of ‘plastic teeth’ showed a massive decline with all perceived associated symptoms seeing a drop of 18% to 36% (see Figure 2).
A clear sign of changing attitudes can be seen in Figure 3 below, where mothers seeing IOM as a treatment option for their child is down to 23% from 64%, whereas the numbers of those seeking hospital treatment instead has increased seven-fold!
However, there is still a belief that ‘plastic teeth’ exist and can cause death and illness. Yet Figure 4 shows that those who believe that death is a realistic outcome has fallen considerably from 84% to 65%.
Another encouraging sign is how the post-training survey shows an increase of awareness on IOM from 84% to 96% (see Figure 5).
Figure 6 also shows that after six months of programme implementation, those who believe IOM is a bad treatment has increased from 40% to 67%, while those who see it as a good treatment has seen a similar shift, decreasing from 49% to 23%.

Conclusions & Lessons Learned:

To the best of our knowledge there has been no other intervention or education carried out either locally or nationally around the issue of Infant Oral Mutilation during the time period that our training and surveys were carried out. This second programme in the Kagera Region of Tanzania has confirmed what we had found in the Tarime pilot study, which is that these cascade training workshops have clearly had the desired impact of shifting attitudes within local communities away from the myth of ‘plastic teeth’ while highlighting the dangers of IOM.

One of our key lessons from the pilot was increasing penetration of our messaging into schools by including District Education Officers in our programmes. As part of our 3-month supervision visit to the District in September 2022, the delivery team checked that schoolchildren were being educated on the dangers of IOM. The team visited 21 schools (4 secondary and 17 primary) and found that children had been taught by the Bridge2Aid trained teachers that IOM was child abuse and led to complications such as bleeding, infections, missing teeth and death. The pupils were questioned and they proved that they were now aware that whenever a child is sick with symptoms such as increased body temperature, vomiting and diarrhea that are mistakenly linked to plastic teeth, they should be taken to hospital for treatment instead of to traditional healers for IOM or ‘rubbing’ with traditional herbs.

These programmes show the potential if this work were to be scaled up in similar areas of Tanzania, as well as other countries. We at Bridge2Aid have therefore developed plans to increase the number of training sessions across northern Tanzania in 2023. We have also developed our own performance matrix which will help us analyse data and compare these between other programmes to monitor changes and further inform future programme.

We would like to acknowledge and thank our funders:
Adavale
Bridge2Aid Australia
Ecograf
Henry Schein
Orecorp

And the clinical expertise and advice of:
Baraka Nzobo
Andrew Paterson

Contact : andrew.carey@bridge2aid.org

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These Participant Conditions are made between Bridge2Aid (UK registered Charity Incorporated Organisation No. 1170578), and the applicant who agrees to the participant conditions below on the signing of this document.

  1. If any of these Participant Conditions are found by any Court or other competent authority to be wholly or partly unfair or unenforceable the validity of the rest of the Participant Conditions and the rest of the condition in question shall not be affected and shall remain valid and enforceable to the full extent permitted by law.
  2. These Participant Conditions are governed by English law and I irrevocably submit to the non-exclusive jurisdiction of the English courts.

1. Finance

It is possible to fund most of your trip by fundraising. However the Initial Deposit of £150 must be paid by yourself. All funds must be paid to us by the due dates, which are set out in the Summary of Costs, and this is sent to you once a Dental Training Programme place has been offered. Please note payment can be made by instalments or at any time as long as the appropriate amount has been received by the due date as shown below.

Generic Summary of costs and payment dates

    1.  I agree to pay Bridge2Aid the £150 Initial Deposit to reserve my place. If I am a new Volunteer, I will then take part in the necessary pre trip training.
    2. I will pay the 1st Instalment of £350 by 34 weeks prior to the trip leaving. I understand that around 4 weeks prior to this date I will receive a statement from Bridge2Aid Finance as a reminder that the payment is due.
    3. I understand that up to the due date for the 1st Instalment I can withdraw from the Dental Training Programme and my Initial Deposit of £150 is refundable. After this date no refund of deposit is available.
    4. D. If I choose to fundraise through an online platform (such as Just Giving), I agree to include the following sentence within the information I provide for donors. ‘Should I for any reason be unable to attend the trip or the trip is cancelled, any funds donated will be retained by Bridge2Aid in pursuit of its charitable aims.’
    5. I understand that if I fail to make the 1st Instalment payment of £350 by the due date, my place may be offered to another volunteer and my Initial Deposit of £150 will not be refunded. I may be offered the opportunity to transfer to another trip in which case the deposit is transferrable.
    6. I agree to pay Bridge2Aid the balance of all remaining costs by the dates set out in the Summary of Costs. This covers Dental Training Programme accommodation, travel, food etc. as well as a small contribution to the general running costs of the Programme.
    7. If I am fundraising and fail to raise sufficient funds by the final payment date I undertake to personally pay the shortfall.
    8. If having paid the first instalment I then fail to make subsequent payments on time I understand Bridge2Aid may withdraw my place and the Initial deposit plus the first Instalment will not be refunded (total £500).
    9. I understand that any notice of cancellation must be given by email to the B2A Programme Delivery Coordinators or in writing to: Bridge2Aid, The Keepers, Symn Lane, Wotton under Edge, Gloucestershire GL12 7BD.
    10. If I withdraw or cancel between 26 weeks (due date for 2nd instalment) and 12 weeks prior to departure the deposit plus first two instalments must still be paid and will not be refunded (total £1,000) – if flights have not been booked then deposit and 1st instalment only must still be paid and will not be refunded.
    11. If I cancel 12 weeks or less prior to departure then the full costs of my trip must still be paid and will not be refunded nor are they transferrable to future trips except in exceptional circumstances.
    12. Travel Insurance
      • Bridge2Aid has a group travel insurance policy with Banner to cover all volunteers up to 16 days (this includes 2 days for an extension/safari trip should I choose to do this). The cost of this is included in my trip fees.
      • If I choose to stay longer than 16 days I will ensure that I have adequate insurance for the additional days spent in East Africa or elsewhere before returning home.
      • Bridge2Aid will send me a summary of the group policy before I book my flights.
        • I understand that I will be notified when my flight has to be booked and that the notification will include the flight route and the necessary timeframe in which the booking must be made.
        • I understand the booking has to be made through Wotton Travel Ltd and that Bridge2Aid will pay the cost from the funds they have received for my trip.
    14. I understand that if I make any variation to the Bridge2Aid selected flight schedule (for example because I stay on for a holiday) then I am liable for any additional flight costs which may result.
    15. I understand that money from fundraising cannot be used to cover the costs of a safari or any extension trip I may choose to take. I acknowledge that Bridge2Aid is not responsible or liable for the provision of any such trip, or for arranging any excursions or other tours or for anything that happens during the course of any trip, tour or other extension.
    16. If I raise more money than I need to meet the costs of my trip I understand that these funds will be retained by Bridge2Aid to use in pursuit of its charitable aims.
    17. It may be possible to carry excess funds forward to a future Dental Training Programme provided it takes place within 18 months of the end of the programme with surplus funds. The Bridge2Aid Finance Team must be notified of this on my return from that Dental Training Programme
    18. I understand that any Gift Aid claimed on donations towards my Dental Training Programme belongs to Bridge2Aid and therefore cannot be allocated towards my trip.

2. Travel, Health and Wellbeing

I understand that in the event that any of the statements set out below are found to be untrue, Bridge2Aid shall be entitled to cancel my trip and any moneys received by Bridge2Aid prior to cancellation shall be retained by Bridge2Aid. In the event of such cancellation, I shall reimburse to Bridge2Aid any reasonable costs, losses or expenses which Bridge2Aid may incur or suffer as a result.

I confirm that:

  1. I will be at least 18 years old on the date of departure.
  2. I confirm that my general state of health and fitness is good and I take full responsibility for my fitness to take part.
  3. I will ensure that I get the necessary inoculations and malaria prophylaxis for my trip.
  4. I am aware that I may be required to provide a letter from my GP confirming fitness to take part in volunteer activities if Bridge2Aid feel this is necessary.
  5. I will have adequate and valid travel insurance for any additional days spent in East Africa or elsewhere which are not covered by the Bridge2Aid group travel policy with Banner. Please see point 1.L above for more details.
  6. If I do not have adequate and valid travel insurance for any additional days by no later than 6 weeks prior to departure, Bridge2Aid may withdraw my place.
  7. I consent to Bridge2Aid contacting Banner in the event of an insured event occurring, if I am unable to do so myself due to ill health, lack of access to communications or any other reason.
  8. (NB Dentists only) I will arrange adequate and valid indemnity insurance to practise in my professional capacity during the Bridge2Aid programme. If I do not provide proof of this at least 8 weeks prior to departure Bridge2Aid may withdraw my place or oblige me to obtain further insurance if Bridge2Aid believes that my insurance cover is inadequate.
  9. I do not suffer from alcohol or drug dependency, or from any chronic condition which might become acute during my trip.
  10. I do not have any criminal convictions which would prevent me from carrying out this volunteer work.
  11. I confirm I am aware of the pregnancy clause below:
    • We are required to carry out a risk assessment for all pregnant volunteers to identify any risks to both the mother and her unborn child, and to implement suitable measures to control any risks so far as is reasonably practicable.
    • We have identified a potentially significant risk, being the lack of medical assistance available in East African countries.
    • If it is not possible to identify a way of removing or reducing the risks we have identified, we may have to consider suspending you from volunteering with us for as long as it remains necessary for the protection of your health and the health of your unborn child.
  12. I participate at my own risk and Bridge2Aid shall have no liability for any loss or damage incurred by me, however arising, or for cancellation of the visit for any reason outside its control. This exclusion of liability does not apply to liability arising in connection with death or personal injury resulting from Bridge2Aid’s negligence, or from Bridge2Aid’s fraud or wilful default.
  13. Bridge2Aid will not be responsible for (and I agree to indemnify Bridge2Aid against) any costs, claims, losses and expenses arising including costs of repatriation e.g. flights and legal expenses.
  14. Bridge2Aid shall not be liable for any changes to itineraries, schedules and accommodation.

3. Code of conduct

  1. I agree to uphold the highest standards of professional and ethical behaviour at all times as detailed in the Bridge2Aid Code of Conduct (Appendix 1 – please see below).
  2. I will adhere to Bridge2Aid’s guidance on appropriate behaviour during the visit, and understand that failure to do so may lead to my being excluded from activities during the visit or future volunteering at Bridge2Aid’s discretion, as normally exercised by representatives of our Implementation Partner or the Site Clinical Lead (SCL) in consultation with the UK team.

4. Passport and Visas

  1. My passport must have at least six months to run from the date I return to the UK.
  2. If I am refused passage and/or entry/exit to or from the country hosting the programme, any additional costs incurred are my responsibility.
  3. It is my responsibility to organise and pay for the appropriate Visa for my trip.

5. Data Protection

I give my consent to the information I provide to Bridge2Aid being made available to other parties as deemed necessary by Bridge2Aid for the purposes of my trip. This can include but is not limited to the following:

  1. Bridge2Aid UK staff and volunteers – to enable processing of my application, my pre trip training and support, and in case of any medical emergency.
    Implementation Partner staff – to support the planning for each trip and to take into account the needs of volunteers e.g. diets, allergies & in case of any medical emergency
  2. Volunteers on my trip:
    • Senior volunteers such as Site Clinical Leads and Assistant Site Clinical Leads. This will include sensitive personal data such as relevant medical history to ensure appropriate support is provided to DTP volunteers when travelling to DTP, and during the programme.
    • Other DTP volunteers will receive basic contact information to facilitate communication between participants, particularly before departure.
  3.  Agents of and suppliers to Bridge2Aid in the UK and abroad, such as travel agents (Wotton Travel Limited), and accommodation and subsistence providers.
  4. Medical professionals, as required, in the event of my needing medical care during my trip.
  5. Photos and videos of the volunteer team are routinely taken to promote the work of Bridge2Aid in print, electronic and social media to advertise, support and promote our charitable work. In signing these terms and conditions I agree to my image being used in this way.

Bridge2Aid will at all times pay due regard to my right to privacy concerning my information and will handle all data with appropriate sensitivity.

6. Safeguarding and Whistleblowing

  1. Bridge2aid takes the protection and safety of all our employees, volunteers and beneficiaries seriously. We are conscious that we are working in areas with children and potentially vulnerable people.
  2. All volunteers must have read the Bridge2Aid safeguarding and whistleblowing policies and signed a statement of commitment to the policies prior to commencement of their programme.

Appendix 1: Bridge2Aid Code of Conduct

Our commitment to you

It is important to Bridge2Aid that quality is at the heart of everything we do, and that we demonstrate and promote a positive attitude, equality and teamwork. Bridge2Aid will adhere to the following standards at all times.

We will give you:

  • Clear instructions about your volunteer role which will include: working time, location, suitable clothing, travel, accommodation, food and any other requirements.
  • A detailed role description, but where possible and reasonable volunteers should be prepared to be flexible.
  • Training for your role
  • A healthy and safe environment with appropriate clinical and infection control standards adhered to at all times
  • Appropriate supervision with a named leadership and administrative team.
  • An opportunity to develop your skills, meet like-minded people and enable you to gain a better understanding of oral health in a lower income country setting.

Your commitment to us

As a volunteer for Bridge2Aid you should recognise that you represent our organisation at all times and as such should not behave in any way that brings the charity into disrepute. Nor should you compromise the high standards of professionalism which are required on a Dental Training Programme.

In particular you should be aware of the following:

Volunteers are expected to:

  • not engage in sexually inappropriate behaviour (as detailed in the Safeguarding policy), whether with team members or others
  • not drink or smoke during working hours
  • not drink alcohol to excess or engage in drunken behaviour outside working hours
  • not use sexist, racist, abusive or culturally insensitive language
  • not act in a violent or aggressive way
  • not take illegal drugs
  • not to take part in any activity, or put yourself in a situation, which is not covered by the group travel insurance policy. This applies to both the Dental Training Programme and time spent on safari or any other extension activity.

You should always:

  • Maintain high standards of ethical integrity
  • Dress professionally while working and follow all usual guidelines on use of PPE
  • Maintain high standards of personal hygiene
  • Show respect for everyone you encounter, regardless of colour, race, religion or gender. For example making fun of or mimicking colleagues or anyone else will never be acceptable even if only intended as a joke.
  • Be very careful when using social media. Naming people, commenting on and making judgements about East African society, its people and its government must be avoided as this can cause great offence. Please be sure to always ask permission when taking photos of Implementation Partner staff, Health Care Workers, members of the community or other volunteers.

Confidential information

As a volunteer you have an obligation to protect confidential or personal information in relation to other volunteers, trainees or patients. If you have access to confidential information (including addresses, telephone numbers or medical information) of colleagues or patients you should never discuss or disclose such information to anyone other than the person/s authorised to receive it both during and after your involvement with the volunteer programme.

As highlighted in point 3 above, failure to adhere to any of the points mentioned in ‘Your commitment to us’ may lead to your exclusion from activities during the programme or even immediate termination of your volunteer placement and return to the UK at your own expense. This may also affect future volunteering opportunities with our organisation.

Other matters

Grievance resolution – A grievance is a perceived or real issue which causes resentment, suffering or distress and which may be regarded as grounds for complaint. Bridge2Aid is committed to encouraging an open environment in which all volunteers can express themselves freely and responsibly, where issues raised are responded to in an appropriate and timely manner and where everyone is treated with dignity and respect.

If you have any concerns about the behaviour of people in your team during your trip, please report it to your Site Clinical Lead, Assistant Site Clinical Lead or the Implementation Partner Programme Manager as appropriate.

After your trip any complaints or concerns can also be reported to the B2A Programme Delivery Coordinators as part of the post programme feedback process. We will treat all feedback as confidential and will seek to protect individuals making such reports from recrimination. All reports will be investigated promptly and fairly.

Performance issues/inappropriate professional practices – we always attempt to resolve any professional performance issues or conflict fairly. If an issue arises during our programmes, the appropriate person will discuss their concerns with you and seek to resolve the matter in a quick and professional manner.

PLEASE REMEMBER: these guidelines are in place to ensure both your safety and that of other people. They are not designed to be restrictive in any way or to diminish your enjoyment of your volunteer experience.

We would like you to know that the time you give up is very much appreciated.

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