Intersectoral oral health promotion interventions for schoolchildren living in remote rural Andean communities: a realist evaluation

Abstract

Background:

Intersectoral oral health promotion entails the participation of local communities. IOHP interventions were introduced in Peru in primary schools in 2013 but oral health among schoolchildren living in rural Andean communities remains suboptimal.

Objectives:

To understand the contextual elements and the underlying mechanisms associated with intersectoral oral health promotion interventions’ current effects on schoolchildren living in remote rural Andean communities.

Method:

A realist evaluation was carried out in three rural Andean communities where intersectoral oral health promotion interventions aimed at schoolchildren have been implemented. Following an evaluation of the effects among schoolchildren, contextual elements and mechanisms were explored with various stakeholders involved in intersectoral oral health promotion through focus groups and semi-structured interviews. Subsequently, an iterative data analysis and a validation process resulted in the identification of context-mechanism configurations.

Results:

Previous positive experiences of collaboration, a focus on communication, feelings of being respected and considered, and development of leadership and trust among stakeholders involved in intersectoral oral health promotion were elements of configurations that positively influence intersectoral oral health promotion. On the other hand, unfavorable physical, social and political environments, previous negative health experiences, feelings of not being respected or considered, demotivation, development of mistrust and insufficient leadership were shown to negatively influence outcomes.

Conclusion:

This research highlights the complexity associated with the deployment of intersectoral oral health promotion interventions in rural communities. Local stakeholders should be further involved to build trust, to facilitate coordination processes among remote rural communities and oral health professionals, and to optimize deployment of intersectoral oral health promotion interventions.

Keywords

oral health promotion schoolchildren rural communities realist evaluation

Introduction

The prevalence of oral health (OH) diseases among schoolchildren remain significant in Latin America (1,2) and in Peru (3 –5), mainly among those living in rural (1), marginalized (3,4), or low-economic status communities (1 –5). In Peru, as in many middle-income countries, current OH inequities in health are related to the social determinants of health (3,4,6,7).

To ensure sustainable change (6 –9) and strive for more equity, social determinants must be addressed through ‘the implementation of effective and appropriate OH policies and interventions’ (7) such as intersectoral oral health promotion (IOHP). Intersectoral actions involving local stakeholders can address the social and economic structural factors contributing to a problem (10). To implement these actions, intersectoral collaboration, defined as a collective action where several stakeholders from different sectors with a relationship of trust (11,12) and a common goal take on different roles (11 –13), is essential (13). Intersectoral collaboration is unfortunately not always present in practice (13,14), and intersectoral actions are often poorly evaluated (15,16), making continuous quality improvement changes difficult to identify and to implement (15).

In Peru, the Ministry of Health developed an IOHP initiative in 2007 (17). In 2013, this initiative was integrated into the national health plan for schools. According to the plan, OH professionals should perform various IOHP interventions in schools: 1) workshops on OH, 2) toothbrushing and flossing demonstrations, 3) distribution of toothbrushes and fluoride-containing toothpaste, and 4) the application of fluoride and sealants (18). Teachers are also involved in IOHP by performing daily promotion of toothbrushing and by ensuring that every child has a toothbrush and fluoride-containing toothpaste available at school (18 –20).

The Peruvian IOHP is the responsibility of OH professionals working in public health centers. However, their actual deployment is uneven across the country (21), particularly in the remote rural Andean areas (22), and the form and level of involvement of community stakeholders are not clear. Certain factors partially explain this situation, including the shortage of OH professionals (23), the low involvement of other health professionals in IOHP (24), and the fragmentation of the Peruvian health system where policies are developed by the Ministry of Health while implementation is managed at regional and local levels (25).

Considering the suboptimal deployment of IOHP interventions in remote rural Andean communities, it is important to understand how such interventions work in depth (9). To do so, we must understand which contextual elements and underlying mechanisms underpin deployment of interventions and the level of collaboration among local stakeholders. This process could facilitate the adaptation of IOHP interventions to local circumstances and optimize intersectoral collaboration. The aim of this research was to understand the contextual elements and the underlying mechanisms explaining IOHP outcomes on schoolchildren living in remote rural Andean communities.

Methods

Design

This article describes the third phase of a project that aims to evaluate, with a realist evaluation (RE), the deployment of IOHP interventions carried out for schoolchildren in remote rural Andean communities (26). RE is theory-driven and allows exploration and understanding of the influences of context and the underlying mechanisms on intervention outcomes (27). RE is iterative and consists of four steps: initial program theory development; a mixed data collection process; data analysis and development of context-mechanism-outcomes configurations (CMOC) that highlight relationships among context, mechanisms, and outcomes; and the refinement and validation process of CMOC (28).

In the first phase, potential contextual elements and underlying mechanisms that might influence the implementation of intersectoral health promotion interventions in schools were mapped (29) and an initial program theory of the Peruvian IOHP interventions in rural communities was developed (30). In the second phase, IOHP outcomes were documented in schoolchildren, using quantitative measures including dental examinations and validated questionnaires (31). In the subsequent phase, focus groups and semi-structured interviews with various stakeholders involved in IOHP were conducted; they were presented with measured outcomes, and by inference explored contextual elements and mechanisms (28) to identify which mechanisms were triggered in the given predetermined contexts. This process was intended to lead to a better understanding of the causal pathway (28,32).

Ethical considerations

This research project was approved by the Comité d’éthique de la recherche en santé chez l’humain du Centre hospitalier universitaire de Sherbrooke (project #2016-1344). Participants were informed that research data would remain confidential and anonymity would be preserved.

Participants

Stakeholders were recruited according to theoretical sampling (33), so that all types of stakeholders involved in IOHP would be represented: 1) OH professionals, 2) teachers, 3) parents, 4) education managers, 5) health managers, and 6) other community stakeholders. Teachers, parents, and other community stakeholders were recruited in three remote rural communities where the second phase of this project was conducted (31). OH professionals were recruited in the health center that provides coverage to the participating remote rural communities. Education and health managers were recruited from local and regional authorities involved. They were identified and approached by a research assistant who spoke both Spanish and Quechua to inform them of the research project and to gather their formal consent to participate. Participants volunteered to participate.

Data collection

Focus groups were conducted with each of the types of stakeholders (except for OH professionals and education and health managers) in each community (when possible) to further analyze how IOHP interventions work and to identify the different contextual elements and mechanisms involved (28,32). Each focus group had between 4 and 10 participants. The open interview grid used (34) respected the principles of realist interviews (35), and was developed from the potential contextual elements and mechanisms identified in the first phase of this project (29).

To gain a more in-depth understanding of the various emerging themes, semi-structured interviews were conducted with representatives of each type of stakeholder involved in IOHP and of each of the participating communities. Interviews were conducted in the living or working environment of participants with a similar interview grid enhanced by focus group data. When agreed and available, some stakeholders who had participated in focus groups also participated in interviews.

Focus groups and interviews were performed by the same research assistant in Spanish or Quechua according to the language commonly used by participants; they were recorded (34) and transcribed verbatim (33) in Spanish by the research team.

Data analysis

Data was coded with NVivo 11 with a directed content approach (36) adapted for RE. Co-coding was performed by the principal investigator (DAB) and a research assistant from the Spanish version (37) to ensure credibility (38). Then, matrix queries were used to explore recurring patterns in data (39), to identify connections (40), and develop CMOC. Memos related to the identification of connections among concepts were written during the coding process and compared with the CMOC generated through matrix queries (41). Final CMOC were revised by co-investigators (LRT and IG), and were validated during a focus group with stakeholders involved in the research.

Results

A total of 59 stakeholders participated in the third phase of this project, comprising eight focus groups and 28 semi-structured interviews. Stakeholder characteristics are summarized in Table 1 (online supplemental file).

CMOC presented in Figure 1 are categorized according to two different levels: 1) contexts and mechanisms (CM) external to remote rural communities, and 2) CM internal to remote rural communities. Each external and internal CM includes contextual elements: situational mechanisms that ‘operate at the macro-to-micro level’ (42); and transformational mechanisms that ‘operate at the micro-to-macro level and show how a number of individuals, through their actions and interactions, generate macro-level outcomes’ (42). CM are also categorized according to their influence on the effects of IOHP interventions as either a positive or negative influence. As will be described, two external and two internal CM exerted a negative influence, while only two internal CM exerted a positive influence on OHP outcomes. IOHP intervention effects related to CM configurations are not presented in this manuscript; these positive and negative outcomes on schoolchildren are being published in another article (31).

Figure 1.

Context-mechanism-outcomes configurations for OHP interventions with schoolchildren living in remote rural Andean communities.

External CM with negative influences on OH outcomes

External CM 1

Intersectoral administrative guidelines had previously been developed by the Regional Directorate of Education and Regional Directorate of Health, on the deployment of health promotion interventions in primary schools (context). When deploying IOHP interventions, the health and education administrators did not have the same attitude toward the aforementioned health promotion activities (transformational mechanism 1) and there was insufficient mutual understanding of the deployment process of IOHP interventions (situational mechanism 1). Inadequate communication channels (situational mechanism 2) and deficient coordination processes (situational mechanism 3) between the two sectors also emerged. Some elements of this external CM are illustrated by a health administrator talking about the intersectoral agreement between the regional directorates of education and health:

Therefore, one way or another, we must ally with them because although the goal is health development, it is combined with education. Therefore, yes, there is articulated work, but this is at different levels [regional administration, local administrations and schools]. There is not always an operative plan; there are difficulties, we have seen it. Nevertheless, the agreement has been helping us in some way, with these problems, to open the doors of institutions (Regional health administrator 1).

Another health administrator added to discussion on intersectoral agreement:

Look, in the region, we handle the health promotion area. It is the area specifically in charge of coordinating with the UGEL [local education management unit]. There are annual coordination meetings where we all participate in a round table. It is at this round table that we make agreements, propose road maps and program the activities for the coming year. . . . What does this mean? That the UGEL is committed to incorporate these themes in their class topics. [The education sector] should do this; however, it did not happen as planned last year (Regional health administrator 3).

External CM 2

The lack of human, material, and financial resources (context 1), the academic training of OH professionals who are trained principally for curative rather than OH preventive care (context 2), and the presence of performance indicators focusing on curative care (context 3) have contributed to the prioritization of the curative approach at the expense of IOHP (transformational mechanism 1). These contextual elements, in addition to the geographical remoteness of rural communities (context 4), have also contributed to demotivating OH professionals (transformational mechanism 2), and have affected both their leadership (situational mechanism 1) and the coordination process of IOHP interventions (situational mechanism 2). These words of an OH professional regarding the work in schools and at the health center illustrate the limits of capacity and of this external CM overall:

We have goals [of dental restorations to achieve], therefore it is a little bit difficult, because, let’s say, I go to schools, I attend to [schoolchildren]. I come back here to the health center [in the district capital] and there are other people waiting for me to attend to them [for curative OH care]. I sometimes feel tired, because I have done my work, I have completed my shift and all, but I arrive and there they are waiting for me. It is therefore difficult sometimes for me to attend to all [children and adults living in rural communities and in the district capital]. That is the problem (OH professional, district capital).

Related to this configuration, a health administrator expressed:

There is quite a wide gap in human resources for this sector. Is this the main weakness? . . . And also our colleagues from the universities, where professionals are trained in a purely curative approach (Regional health administrator 1).

Internal CM with negative influence on OH outcomes

Internal CM 1

Most rural community stakeholders and parents have had negative experiences with health professionals in the past (context). Additionally, these rural community members reported feeling geographically, socially, and politically isolated. The social environment (including the traditional lifestyle and practices) in remote rural communities was also identified by several stakeholders (context). These contextual elements have contributed to the development of a feeling of not being considered or respected by health professionals (transformational mechanism). When IOHP interventions were introduced, parents and rural community stakeholders also had high expectations (transformational mechanism). The conjunction of these contextual elements and transformational mechanisms has contributed to the development of mistrust toward health professionals including OH professionals (situational mechanism). A few elements of this internal CM are illustrated by the remarks of a health administrator:

Then, many parents or teachers feel that they have been misled, because, as they say: ‘you told us that you would provide for us and you have not delivered. Therefore, why should we participate if you do not comply?’ (Regional health administrator 3).

Internal CM 2

In some rural communities, there have been previous social and political tensions among some community members (context). This situation led to the demotivation of stakeholders in IOHP interventions (transformational mechanism) and affected their ability to assume leadership within the community (situational mechanism). A local authority talking about the level of involvement of some community members said:

When we talk to the people of the community about these things, they don’t want to listen. This is why, as authorities, we do not participate much in these activities; we sometimes talk to [community members] about something important and they act as if they do not want to listen. They say they are in a rush, or they began to talk among themselves. This demotivates us from continuing with the awareness program (Local authority 2, Community 2).

Internal CM with positive influence on outcomes

Internal CM 3

Some teachers have positive lived experiences of collaboration with parents and community members (context). Considering the impact of poor OH on the children’s learning process, teachers have developed a proactive attitude toward promoting OH (transformational mechanism). Some teachers have developed leadership in the communities related to IOHP (situational mechanism 1), and initiated a coordination process with some communities’ stakeholders (situational mechanism 2). This internal CM configuration fostered the emergence of the following configuration (internal CM 4). As one teacher expressed:

We talk to [health professionals]; well, this can be done, for sure. However, as my colleagues say, it does not go as far as planning. Therefore, we must be there, get involved in the preparation of material and carry on a campaign together with the nurse, so that the parents also get involved in this. . . . We are doing it because the children are always with toothaches. Because we are concerned, we will always keep on this work about oral health (Teacher 2, Community 3).

Internal CM 4

Previous positive experiences of collaboration with teachers within communities (context) combined with the positive attitudes of some parents and community stakeholders toward OH (transformational mechanism) have fostered the development of a relationship of trust (situational mechanism 1) and complementarity (situational mechanism 2) among community stakeholders involved in IOHP. A parent pointed out various elements included in internal CM 3 and 4:

Yes, [teachers] involve [parents and community members]; they inform us about on-going activities, because there is a communal agreement. It is a verbal agreement with the communal president and the whole community. It would not be right if they did not inform us. As service users, we must also participate in the agreement and the activities (Parent 5, Community 3).

Two mothers shared details about their involvement in IOHP and in other community activities:

If we, as steering committee, or as parents, did not support the teachers, they would no longer feel like keeping on with the work; this is why we always do what they ask us (Parent 2, Community 1).

As I now know how to care, I have to put it in practice. I don’t want my children to be like me, I make them brush and take care of their little teeth. When children do not have all their teeth, it disfigures their face and they look as if they were older. Some time ago, a health professional came over and taught us how to care for ourselves. So, I also take care of my little one, because I don’t want him to be like me (Parent 4, Community 1).

Discussion

Using an RE, this study highlights the complexity associated with the deployment of IOHP in remote rural settings. A cascade of dynamics among contextual elements and mechanisms external and internal to remote rural communities trigger mainly negative ‘ripple effects’ on the deployment of IOHP and the development of collaboration between OH professionals and other stakeholders. This process decreases IOHP benefits for schoolchildren.

Complexity in health community interventions, the impact of the system-level on the community-level (43), and the concept of a ripple effect in community-based interventions (44) have been discussed previously, but this is the first study to describe and discuss these elements within IOHP and to highlight the presence of negative ripple effects. Through the use of focus groups and interviews with various stakeholders concerned with IOHP, this research allows a broader understanding of the perspectives of different stakeholders (15). This can in turn improve the effectiveness and sustainability of an initiative (44), particularly for the development of intersectoral collaboration in IOHP.

One of the key elements to consider in the deployment of IOHP is the management of financial and material resources in the developmental stage (8,45 –47). As this project and other scholars have shown, the lack of stable financial resources affects both the deployment and monitoring of IOHP interventions (12,48), particularly in remote areas considering the costs associated with remoteness (49). The Peruvian health system faces several other health priorities, particularly in rural areas (25), which may explain the limited resources deployed in OH.

Emphasis must also be placed on human resource management (50). In Peru, as in many other countries, there is currently a lack of OH professionals working in rural settings (23,50,51). The workload of OH professionals working in these regions is heavy, their recruitment is difficult (23,50), and most are not well prepared to execute this particular role (20,50). In rural settings, OH professionals must often work in a culture different from theirs, and must collaborate with various stakeholders to carry out IOHP, despite being poorly trained or even untrained for these tasks (50,51). Building relationships with parents is another crucial element, because the existence of previous negative experiences in relation to OH might affect the development of trust with OH professionals (52,53). Therefore, themes related to cultural competency (51), the humanist approach (8,23), OH promotion (8,52), and interprofessional (47,51) and intersectoral collaboration (8) should be addressed in more depth in OH professionals’ academic and continued training. These skills would enable OH professionals to be more responsive to the needs and particularities of disadvantaged communities (6,20).

Other key elements to be aware of are the social and physical environments where a program is implemented, particularly in rural settings (54). Program implementers should rapidly identify the challenges (geographical remoteness, social isolation, poverty, limited access to health services, etc.) (50,54,55) and assets (social relationships, existing physical infrastructure, volunteering) (54) present in rural areas where a program is being deployed. Afterwards, it is essential to identify and put in place ways to minimize the identified challenges (50,54) and to maximize the use of existing assets (54).

There is a need to rethink IOHP as it is currently implemented in Peru in order ‘to develop context-specific strategies’ for local communities (6). OH education, which is an important component of current IOHP interventions, cannot alone produce lasting change among schoolchildren (56,57). To increase access to IOHP interventions and data about their impact, it would be necessary to extend OH promotion initiatives to other health professionals such as nurses (9,24,47,51,52) and to involve more local stakeholders such as teachers, parents, and community members (communal assemblies, school parent associations, local health promoters, community shopkeepers) in the development, implementation, and deployment of interventions (8,45,50,51). The development of collaboration with communities’ stakeholders and other health professionals would enable the identification of local challenges and assets (54), which could lead to interventions to improve socio-economic conditions in rural communities (7). Intersectoral collaboration could subsequently facilitate the adaptation of IOHP interventions to local circumstances, increase their adoption by the local population, and ensure future sustainability (8,51). In addition, the involvement of parents in IOHP predisposes them to have a more favorable attitude toward OH, which might contribute to increased toothbrushing frequency and other positive OH behaviors for their children (58).

Unfortunately, a top-down approach, (46) as used for the implementation of the IOHP initiative in Peru, and the short-term vision of authorities have hindered or even stopped (in certain communities) collaboration with local stakeholders (45). To foster the emergence and sustainability of collaboration, emphasis must be placed on the coordination (45,47) and communication processes (including the development of a common language) both at the management and community levels (12,46), and also between these levels (46,59). This will help to better comprehend the perspectives of the members involved (15,46), and facilitate the development of trust and a common vision on OH promotion among partners (12,59).

Limitations

The major issues encountered during this project were language and cultural barriers, which could have influenced the interpretation of data (37,60). However, the translation process used before data analysis (37) and the presence of a local bilingual research team (which included an anthropologist) limited the impact of these barriers on the analytical processes. Furthermore, although efforts were made to include a broad range of perspectives throughout this research, elite bias may be present. Triangulation of sources and methods, and examination of multiple cases and the final validation with a group of stakeholders would serve to mitigate the impact of such bias (33).

This research provides a better understanding of key elements that have led to suboptimal IOHP outcomes on schoolchildren, and how IOHP interventions actually impact remote Andean rural communities. These results will contribute to discussions on how to reorient IOHP interventions in remote rural areas and to improve intersectoral collaboration among various local stakeholders.

Footnotes

Acknowledgements

We thank the students involved in the Ciclo de estudio “Pierre Fauchard”, carrera profesional de odontología, Universidad San Antonio Abad del Cusco, Raimunda Ccoyo Quispe, Jhon Vargas García, professor Palmira La Riva Gonzales and professor Fernando Murillo Salazar for their help and advice. Thank you also to Meg Sears for her linguistic revision.

Declaration of conflicting interest

The authors declare that there is no conflict of interest.

Funding

This work was supported by doctoral scholarships from Fonds de recherche du Québec - Santé, Ministère de l’Enseignement supérieur, de la Recherche et de la Science du Québec and the Faculty of Medicine and Health Sciences, Université de Sherbrooke.

ORCID iD

Dave A. Bergeron

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