Bridge2Aid News

Oral Health Cascade Training in Remote and Rural Northern Malawi

[11/04/2022]

This is a guest post that has been compiled and edited by Andrew Paterson and originally published by Jeremy Bagg via The Maldent Project blog. 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

rural malawi

80% of the population of Malawi live in rural areas

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.

 

dental therapists malawi

Dental therapists hard at work designing the teaching course

 

oral health training slides

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.

 

 

 

malawi dental therapist

One of the therapists demonstrating toothbrushing to the volunteers

Two newly trained community volunteers practise teaching their recently gained toothbrushing skills to others

tooth decay chart

An excerpt from the oral health flip chart. Community volunteers had simple tools in a language understood by their communities to aid key oral health message delivery. Here is an explanation of tooth decay

 

 

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.

Martha Chipanda

Martha looks on as one of the community volunteers receives their oral health promoters course completion certificate

 

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.

smoking cessation malawi

Flip chart messages: Empowering community volunteers to cascade key oral health messages also impacts general health. Volunteers have the tools to encourage smoking cessation

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.

capacity building

Capacity building: A single trained community volunteer can deliver essential oral health messages to many in their community

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

 

students malawi

Community volunteers learning from a dental therapist trainer

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!

cascade training

Successfully completed cascade training: Martha, the dental therapist trainers and the first cohort of trained community volunteers

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!

 


Myth-busting – news about a new face-to-face training programme

[21/02/22]

In rural Tanzania education around oral health is extremely limited.  It is widely thought that ‘tooth worms’ are responsible for causing dental caries.  When a tooth is removed the worm flees to another tooth and continues making new cavities.

 

For people who believe that ‘tooth worms’ are the cause of dental decay toothbrushing is pointless!  They believe that the only reason to brush your teeth is so your breath smells fresh.  We hear a lot about traditional practices, folk medicine and faith healers in African nations.  Often the techniques that they use are portrayed as cruel or malicious.  But in communities where people have little affordable access to healthcare, and community education can be minimal – where should local people turn for help?  Traditional healers are responding to a void, they give people answers and hope of a cure that is affordable.

To change community behaviour, and so significantly impact oral health, we need to ‘bust’ some common harmful myths and replace them with simple medical facts, and easy preventative behaviours.  The only people who can do this effectively are Tanzanian health workers and respected member of local communities.  They understand the context, the community and the myths.

 

Bridge2Aid have been working on a big education and ‘myth busting’ pilot project this month.  We’ve developed training with Dr Nila Jackson (a local dentist in northern Tanzania) and the Global Child Dental Fund, to address a very damaging practice that is carried out across much of East Africa.  This practice is called infant oral mutilation (IOM).  This happens when a very young child is taken to a local healer with sickness and diarrhoea.  If the healer can feel the ‘tooth buds’ of the emerging canines through the child’s gums, then they may diagnose these as ‘plastic teeth’.  To prevent the illness getting worse it is thought that the ‘plastic teeth’ need to be removed.  This is done using the very basic tools that a local healer has, most usually a sharpened bicycle spoke.  Using this unsterilised tool, with no efficient way to stop any bleeding, and no form of anaesthetic, the tooth buds are taken out.

This is painful, dangerous, and sometimes deadly.

Often the both the infant tooth buds and the tooth buds that will develop into adult canines are removed at the same time, so the patient will never have canine teeth.

 

Training IOMI went to Tanzania to see the delivery of the first training programme.  Over the course of the training many people shared their stories.  Among them were a woman who was forced to have her first child treated for ‘plastic teeth’.  She said that it was so traumatic that when she gave birth to her second child, she had run away to the region that she was born in.  People in the south of Tanzania don’t share the belief in ‘plastic teeth’, so she ran away there and didn’t return until the child had got its full set of infant teeth.

We also met woman whose child had been diagnosed with ‘plastic teeth’ because she was very sickly. The child lost a lot of blood due to the procedure and became so unwell they had to be hospitalised.  In hospital they child was diagnosed with malaria – which was the original cause of the child’s sickness.  The child very nearly died, but fortunately pulled through.  Several women told us of children of theirs who were not so lucky and had tragically died after this treatment.  There were also attendees who had no adult canines because of this happening to them as infants.

 

There used to be traditional treatments for polio and HIV/AIDS before intensive community education took place, and easily accessible medical treatments were available. Now nobody would go to a traditional healer for these conditions.  We wanted to embed knowledge about the truth of ‘plastic teeth’ at a community level so that child ever has undergo this dangerous treatment in the future.  Moving to easily accessible locations, and hiring a local school classroom for the day, we trained nearly 500 people.

 

Our training was delivered over seven days at the beginning of this month (February 2022).  The work was focussed on 6 wards in the Mara district of Tanzania.  The trainees were different groups of people who are influential in the community – including the traditional healers who are currently practicing this treatment.  We began by training the district health management team and district dental officers, then the primary healthcare workers (nurses and clinical officers), community education teams, ward development committee members, religious, village leaders and traditional healers.

 

Training was delivered in Swahili using local facilitators Dr Nila Jackson (a dentist), Dr Alex Kanoni (a dental therapist, the localDr Nila Jackson dental therapists, Dr Msafiri Kabulwa from the Ministry of Health, Ghati Samuel (a community development officer) and Julitha Lesha (a local nurse).  Because the trainers understood the local context and the roots and complexities of these myths in the communities, they were able to speak with authority on the subject and engage in some challenging and sensitive discussions.  Each training session was 4 hours long, so there was plenty of time for members to raise all their concerns and questions.

 

The thing that stuck me most was how widespread the belief in ‘plastic teeth’ was – even among those with medical training, like the nurses and clinical officers.  Many people were also surprised when the practice was described as a violation of the children’s human rights – as it is violence being used against them.  Quite a few of the traditional healers were shocked and upset by the sessions.  Their reaction was generally one of a realisation that this was a practice that has to stop.

 

Sharing the science and the biology was really useful, but so was an using examples of past myths that have been ‘busted’.  One of our trainees was a man in his mid-forties – he said that he was an identical twin.  At the time he and his brother were born, twins were considered ‘bringers of evil’ and had to be taken out of the village and abandoned to die.  His mother had managed to save him and his brother, but this was against all the accepted traditional wisdom of the time.  People now know that there is nothing harmful about twins – but just a few decades ago the myth had nearly cost him his life.

 

Our next steps are to see how effective our training was.  We carried out pre- and post-training questionnaires with the attendees, and we could see that the training had educated and significantly shifted attitudes.  Those attendees who are health workers will also have a 3 and 6 month follow up sessions carried out by Dr Nila and the district and regional dental officers.  We also carried out wide-ranging surveys on the knowledge and attitudes toward Infant Oral Mutilation in the local community.  In 6 months’ time a further survey will be carried out to see if our community educators’ have managed to shift attitudes. We’ll keep you informed as to the progress of the project.

 

Having had the privilege to see some of this training in action I’m certain that we were definitively changing minds and that a significant number of children will be spared the pain and danger of this treatment in the future – as a direct result of this training.  By delivering oral health education we’re delivering pain free futures.

 

There are lots of opportunities for you to volunteer and be involved in the work of Bridge2Aid.  To see how you can help click here.  Or if you’d like to donate to enable us to run more training like this please visit our donation page here 

 

Paul Tasman, Operations Manager.

 


20th March 2020

COVID-19 Update

To our community of Bridge2Aid supporters, partners and volunteers,

As we are all aware, this is a very hard time for many people in the UK and around the world. We’re all concerned about our friends, families and neighbours. As our community, we wanted to keep you updated on with how we are managing the impact of COVID-19 on our work.

Firstly, our office team are healthy, although a couple of us are in self-isolation. We are in the fortunate position that we can all work from home and still get lots done. But there is, of course, a huge impact on our work and it’s unsettling for us, our volunteers, partners and supporters. The two countries that we work in (Tanzania and Malawi) have placed restrictions on their borders and the airlines are in control when it comes to cancellations. This means that we are having to take things day by day and react as new information comes in. We have already made the difficult decision to cancel our April programme in Tanzania and we are reviewing our future programmes and this is our top priority. We are keeping the volunteers within those teams informed as a first port of call. As a small organisation, with a small bank balance, we unfortunately can’t make long-term decisions at this time and we are making decisions with great care based on the information we have. We are obviously devastated that our training programme is currently on hold but we are doing everything we can to keep our office working at full capacity so we can move our work forward as much as we possibly can.

As the whole team is working from home, our office landline is currently unmanned. We are monitoring our emails very closely and mobile numbers can be available in an instance where emails don’t suffice. Please email the contacts you already have or email info@bridge2aid.org

We will be updating our website with any news. Please check our website for the latest information and if you are volunteering on a future programme please be assured we are doing all we can to get the answers to you as soon as possible.

We are expecting some financial difficulties ahead, this is inevitable as fundraising and networking events are cancelled, business and practice income are jeopardised and priorities lie closer to home. We’d like to emphasise how vital your support is to our work. We hope to reach our beneficiaries again soon.

We understand many of you will be worried now, whether it is about the health of loved ones, or about your job, or your business. Our thoughts and hopes are with you and the wider community.

My best wishes to you all
Shaenna

CEO Bridge2Aid


20th June 2019

Tanzanian Oral Health Survey

Last week our Ops Manager Paul Tasman met up with Tanzania’s Chief Dental Officer Dr Ray Masumo to celebrate a huge achievement. All the hard work designing and seeking funding for a National Oral Health Survey for Tanzania has paid off. The survey will be starting soon and the information gathered will be invaluable. This is a joint project and getting this far has been due to working with fantastic partners – namely The Borrow Foundation, MCW Global and Muhimbili University. We’ve had advice and involvement from the World Health Organisation along the way too. We’re thrilled that the survey will be taking place and look forward to being able to share the results with you in a few months time.

 

 


15th June 2019

Newsletter May 2019

 

 

 

 

 

 

 

 

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10th June 2019

Malawi!

Paul,our Operations Manager had a very promising meeting today  with the Malawian Ministry of Health, the Dental Association of Malawi, Glasgow University Dental School and the Medical Council of Malawi. Bridge2Aid has recently won a grant to fund exploring development of the B2A model in Malawi, working in partnership with Dental Association of Malawi and the University of Glasgow Dental School. We’ll be working on this initial assessment project for the next year, so you won’t be able to volunteer to work in Malawi just yet! These are very early days but there is huge potential.

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