Peru interim report 2005

Interim Report

Oral Health Promotion and Integrated Oral Health Care in Rural Schools of the Provinces of Grau and Antabamba, Apurímac, Peru

January 2005 - August 2005

Presented by:

Dr. Walter Mautsch

September 2005

Introduction

This interim report is to inform DHIN and ZME about the visit of the external coordinator to the Region of Apurímac, Peru from June 16th to July 29th and the activities implemented up to now. The time schedule of the visit (in German) is attached to this report and gives the reader a detailed information about the various activities during this time period.

This report will not repeat rationale, aim and planned activities of the project, as it has been documented in the project proposal of January 2005.

Activities implemented

Training of schoolteachers (May, 20th and 27th )

Two one-day courses for primary school teachers of the participating schools in the provinces of Antabamba and Grau were held. 72 teachers and those 11 health workers, who will implement oral health promotion activities participated in the courses. The courses were held by the locally responsible dentists, Dr. Jesus Hernandez and Dr. Dean Cerazo and the regional coordinators of the project, Dr. Rip Vera, Dr. Joaquin Farfán and Mario Paniagua.

Main topics of the seminar were basic knowledge about oral health and preventive measures as well as the discussion about the future activities to be implemented in the selected primary schools. A little manual on oral health and preventive measures had been produced and was distributed to all participants.

Calibration course for dentists (June, 21st to 24th)

In order to get valid epidemiological data, 3 local dentists and 5 health workers were trained in the examination of school children aged 6, 9 and 12, recording data on caries experience (DMF-S and severity of lesion), initial caries lesions, CPI, OHI-S, Fluorosis (Dean-Index), trauma and general hygiene. Unfortunately 2 of the originally 5 dentists did not participate regularly, therefore they could not be considered as examiners in the study.

The final calibration exercise showed a high coincidence (Kappa value 95%) between the local dentists in diagnosing DMF-S and severity.

Epidemiological study in the provinces of Antabamba, Cotabambas and Grau (June, 28th to July, 22nd)

Dr. Mautsch, Mario Paniagua as local coordinator, and the respective local dentist visited 21 primary schools and examined 745 children (age 6, 9 and 12).

Five schools in Cotabambas with a total of 168 examined pupils are considered as control schools where the project activities will not be implemented. It is planned that the local dentist will examine more children in other schools in August and September.

In the province of Grau, all nine participating schools have been visited, with a total of 358 children examined.

219 children of 6 schools in the province of Antabamba have been examined. The local dentist will finish the examinations in August and September.

Apart from the oral data, the majority of the children have been weighed and measured and a questionnaire was done where issues like oral hygiene behaviour, sugar consumption and indicators such as experience with dental pain and limitations in their social life were addressed. The data is now processed in Abancay and will be further statistically analysed in November and December. We therefore hope to have preliminary results at the end of this year.

Testing the contents of fluoride in toothpaste

Dr. Mautsch has collected about 150 toothpastes from little shops, market stands, supermarkets and pharmacies in different districts of Apurímac, thus obtaining a broad spectrum of fluoride toothpastes. The toothpastes will be tested by the University of Brussels (Prof. Bottenberg) concerning the really available content of active fluoride.

Preparation of courses in ART

Contacts have been established with the Pan-American Health Organisation (PAHO/ OPS) and the responsible dentist for ART in the Ministry of Health (MINSA) in Lima. There has been a “Training the trainers course” in Lima in June, where 24 dentists of the different Peruvian departments have been trained. Dr. Waleska de Almeida of the MINSA promised to support our ART courses in Abancay with material. She will participate in our first course from October 10th to 14th for all regional dentists employed by the Regional Health Authority of Apurímac.

Donation of DHIN for ART and courses

The first part of the material donation given by DHIN to Dr. Mautsch has been handed over officially to the Regional Health Authority of Apurimac (DIRESA). This material has been taken with personally by Dr. Mautsch.

Unfortunately the material shipped by DHIN to Lima is not yet released by the customs authority. Apparently there are people who want to show their power and put obstacles to the health authorities. A ministerial resolution has now been issued by the DIRESA to force the customs authority to free the material without payment of toll. Our local coordinator, Mario Paniagua will have to go to Lima in order to receive the material. We hope very strongly that the instruments and material will be complete and will be available for the ART courses in October.

This bad experience demonstrates again that the shipping of donated instruments and material should be considered very carefully. In most cases it is more convenient - and cheaper!! - to buy most of the material and instruments within the country and only import material which cannot be purchased in the country. This last option should be kept very low, as it might lead to a dependency by spending much money on imported material, high maintenance costs and reduced possibilities to create a sustainable project.

Planned Activities in 2005/ beginning 2006

ART course for dentists (October, 10th to 14th)

This course will introduce ART to 21 dentists employed by the Regional Health Authority of Apurímac (DIRESA). The course will be held by Dr. Oswaldo Ruiz from Ecuador who has worked very closely with Prof. Christopher Holmgren and Prof. Jo Frencken in the organization and implementation of ART courses in various Latin-American countries. He is official of the Panamerican Health Organization (PAHO/ OPS). Dr. Waleska de Almeida, national responsible for the ART project in Peru, will also participate as a lecturer. The course will be held in the Regional capital Abancay.

Apart from the main support by DHIN, we will obtain support by MINSA, OPS and 3M ESPE which will provide us with glass ionomer cement.

ART course for healthworkers (October, 17th to 21st )

11 selected healthworkers of the provinces of Antabamba and Grau who already are trained in oral health will be introduced to ART by the locally responsible dentists, Dr. Jesus Hernandez and Dr. Dean Cerazo. As the healthworkers have not yet worked in this field, it is planned to do a first joint course with emphasis on theory of caries development and progression, diagnostic capabilities and practical training in models. After having successfully passed this course, the healthworkers will be trained individually by the dentists in a hands-on course in their health centres and primary schools.

This measure is necessary to counter against arguments of the Peruvian Dental Association which objects to the training of auxiliary personnel in dental care by the Regional Health Authority.

School contest (October, 22nd)

A provincial competition for schools has been initiated during our visits in June and July. Schools are requested to create songs, poems, paintings and theatre plays concerning oral health messages. The participating schools will meet in Chuquibambilla to present their work. There will be prizes for the best schools.

ART in schools (from October)

The trained health workers will start the application of ART in the schools of their communities. The project will provide them with instruments and material donated by DHIN. The locally responsible dentists will have to visit each one of them and work with them for some days in order to make them capable to perform ART by themselves. A monitoring and supervision schedule will be developed.

Development of educational material for schools (Jan to April 2006)

During school holidays, the available dental educational material will be revised and updated.

Seminars for teachers (May 2006)

At the beginning of the new school year, the teachers of the project schools will be informed and trained in oral health and preventive measures. Activities performed in 2005 will be evaluated.

Final remarks

Thanks to the financial and material support of DHIN and ZME the project could be initiated as planned. Apart from minor delays due to local and national problems, such as strike of the teachers or difficulty to get local transport, the planned activities could be implemented on time. The data of the epidemiological survey will give the team the opportunity to reconsider their strategies concerning caries prevention and oral health promotion. The study on the contents of freely available fluoride in toothpastes will hopefully give us arguments for the Ministry of Health to put more emphasis in the control of national and international manufacturers of toothpastes.

The external coordinator has the impression that DIRESA and MINSA are strongly interested in the implementation of the project. The provision with local transport and driver has worked very well during the visit, although there were considerable logistical problems sometimes. In general, there is only one car available in the health centre for patient transport and official journeys. Very often, the cars are on duty or under repair, so that sometimes there were difficulties to have a car available. Nevertheless, all local health authorities have made every possible effort to provide us with local transport.´

The primary school teachers, children and parents have shown a very high interest in the implementation of the project and the coordinators face the problem that other schools and health centres have strongly applied to be part of the project. It was difficult to convince them that it is better to start with a small pilot project and see how it works instead of starting big and achieving little.

The project group is grateful to DHIN and ZME for the support given by them and expresses the hope that both organizations will continue their contributions for the next years.

Dr. Walter Mautsch

External coordinator