CHAPTER 12 PLANNING FOR COMMUNITY DENTAL PROGRAMS
Microbiologist Rene Dubos has suggested that most of human history has been a result of accidents and blind choices.1 When a crisis occurs, our solutions are immediate and involve piecemeal efforts rather than considered and thoughtful planning. The need to develop our ability to predict, plan, and thus prevent the same crisis from recurring should have the highest priority.
As part of our role as health professionals, we are called on to assist health agencies and organizations in developing plans for obtaining dental care. We need to develop our own abilities to take our dental expertise and channel it into the areas of policy development, decision making, and program planning in a system more complex than the one with which we are familiar in the private dental office. This complex system may take the form of a community, an organization, a corporation, or an institution. The system can be better understood if we look on it as a patient, possessing certain needs and characteristics. Because we are dealing with more than one individual, planning a program for a community or institution requires a deep understanding and analysis of the system as a whole and of the individual members that make up the system.
The steps the dentist takes when seeing a patient for the first time can be compared with the steps a planner takes when viewing a system for the first time. A new patient who walks into the dental office is given a medical and dental history form to complete. This record provides background information on the patient’s health, history of diseases, and drug reactions, as well as the patient’s history of dental care. Information on the patient’s ethnic background, degree of education, and financial status may indicate the patient’s attitude about dental care, the type of dental care wanted, and how that care will be financed. A clinical examination with the use of radiographs further reveals the type and quality of dental care received and identifies any existing conditions or disease requiring treatment. For the dentist these steps assess the needs of the patient.
The next step is to identify and diagnose the problem or problems. Perhaps the patient requires full mouth reconstruction to restore the mouth to optimum functioning. The dentist reviews with the patient the ideal plan and acceptable alternatives based on the patient’s wants and financial limitations. Once the patient accepts the treatment plan and the method of payment, the plan is ready to be implemented.
The dentist selects the appropriate person to perform the necessary services from a staff of specialists and designs a realistic timetable to coordinate who will do what first, second, and so on until treatment has been completed.
When treatment has been completed, the patient is placed on an appropriate recall schedule and returns to have an evaluation of the care that was rendered. Any modifications or adjustments are done at this time. The patient is then placed on a maintenance plan and returns periodically for a routine examination. This becomes an ongoing process for the patient and the dentist. The difference between the planning steps for an individual patient and the planning steps for a community is that dealing with more than one individual at a time requires more complex steps. Box 12-1 compares the provision of dental care for a private patient with that for a community.
Modified from Young W, Striffier D: The dentist, his practice, and the community, Philadelphia, 1969, WB Saunders.
Usually a planner is contacted because a problem has been identified within the community, for example, a high incidence of early childhood caries (ECC) among children. The planner, like the dentist, begins by conducting a needs assessment of the affected children and their families. Included in the needs assessment are the population’s health problems and beliefs, ethnic makeup, diet, education and socioeconomic status, number of children with ECC, and the severity of the disease.2 Again, this information will help the planner in determining an appropriate plan.
Once the information has been gathered and analyzed, the planner, along with the community, sets priorities for dealing with the problem. The planner may decide that the first priority is to treat all existing cases of nursing bottle caries within the community, followed by reeducating the parents of these children and those individuals who recommended sweetening the contents of the children’s bottles. The planner then sets a reasonable goal to reduce the incidence of ECC within that community within a specified time and proposes methods or objectives to accomplish the goal.
Next, the planner identifies resources available to the community, such as who will provide the treatment, how the care will be financed, and where the care will be provided. If constraints exist (e.g., no transportation available to bring the children to the dental office or a lack of funds necessary to provide the treatment), the planner needs to consider alternative strategies to accomplish the intended goal. The planner might identify and recruit volunteer dentists or dental students to treat the children at no cost to the community.
After the children have been treated, a 6-month follow-up examination is instituted to evaluate the effectiveness of the plan. At that time the planner addresses questions such as the following: How many children identified as having ECC were treated? How many dropped out of treatment, and why? How many developed new ECC? The answers to these questions will help the planner to modify and adjust the program according to the needs of the community.3
Many kinds of planners exist. Some have been professionally trained or educated, whereas others have received on-the-job experience within their organization. There are two distinct approaches to planning: internal, planning by individuals within the system or organization; and external, planning by those brought in from outside.4 A planner hired from within the system is usually an individual whose work responsibility is to plan for the system on a full-time basis. The advantage of hiring from within is that the planner already has a true understanding of the issues and operation of the system, including the subtleties of that system. This knowledge enables the planner to begin making decisions more quickly regarding appropriate action. The disadvantage, however, is that the planner may already have acquired certain biases about the system that could influence his or her objectivity.
The planner brought in from outside is usually an individual who contracts to work for the company or agency on a consulting basis for a short period. The planner’s job is to assist the organization in its planning by formulating a new proposal or making recommendations for changing an existing plan. The advantage of an outside planner is that the organization may receive a fresher outlook, less bias, and a greater sense of objectivity. The drawback is that the outside planner requires more time to reach a sufficient level of understanding for effective action to take place.
One of the most important concerns for any planner is to take into consideration the human element. Statistics alone do not tell the whole story. For example, a planner who reviews the health labor statistics on a multiethnic community and who sees that, overall, sufficient numbers of practitioners work within the community may think that the community does not need any new practitioners. A closer examination of the practitioner and patient populations may reveal that the practitioners are primarily of a certain ethnic background and do not like treating patients of different ethnic backgrounds, of which there are a great number in the community. Thus large subgroups of the population may not have access to dental care, even though statistically enough dentists are available in the community.5 Although statistics can be most useful in analyzing data, a planner must be aware of their limitations.
Banfield presents a basic definition of the term planning: “A plan is a decision about a course of action.”6 In other words, a plan is a systematic approach to defining the problem, setting priorities, developing specific goals and objectives, and determining alternative strategies and a method of implementation.
Many types of health planning exist. Each varies according to the factors affecting the health system, such as the geography of a region, the sociocultural background of the population, economic considerations, and the political situation. Some types of health planning, as outlined by Spiegel and associates,7 include the following:
This chapter describes various types of health planning but concentrates specifically on the program-planning process. This process of program planning uses a systematic approach, as seen in Fig. 12-1, and should be used as a guide to solving a particular problem. The process can be compared with the ability of a jazz musician to take the notes of a standard musical scale and use them to create a unique melody. In a similar fashion, a planner uses the program-planning steps to create a plan that is unique for the specific situation or system. The process of planning is dynamic. Within a fluctuating and ever-changing system, the process itself must remain fluid and flexible, responsive to the presentation of new factors and issues. This chapter discusses the components of program planning and focuses on the various options available to the planner. The initial step in the planning process is to conduct a needs assessment.
There are several reasons why a planner should conduct a needs assessment. The primary reason is to define the problem and to identify its extent and severity. Second, the assessment is used to obtain a profile of the community to ascertain the causes of the problem. This information helps in developing the appropriate goals and objectives in the problem solution. Assessing the community’s needs not only involves identifying existing health problems but also potential health problems and health promotion needs.8
A needs assessment evaluates the effectiveness of the program. This is accomplished by obtaining baseline information and, over time, measuring the amount of progress achieved in solving the specific problem.
Suppose the planner designed a program to administer fluoride tablets to all school-age children in a given community. To determine how effective a fluoride tablet program is in terms of reduction of dental caries, the planner would first establish a baseline needs assessment of the caries rate among the school children. After the initial assessment, the program is implemented. To measure the effectiveness of such a preventive regimen, the planner would then make periodic assessments of the schoolchildren at various time intervals and compare these results with the initial assessment.
Conducting a needs assessment for a community can be a costly endeavor. If the funds are not readily available, the planner has several options. One option is to coordinate with the research activities of other agencies interested in obtaining similar health information on the given population. For example, a neighborhood health center may be involved in conducting a health survey of all the residents living in a defined geographic area.
Another method is to investigate surveys that have been done in the past by other organizations. Frequently, dental surveys are conducted through research departments of dental schools or through local and state health departments. If no surveys have ever been done, the planner may either want to solicit the assistance of these agencies and organizations or inform them that a survey will be conducted. This approach prevents overlap or duplication of activities.
Whether the planner conducts his or her own survey, combines efforts with others, or uses information from past surveys, it is important to consider what type of information is needed and how it should be obtained. Data can be obtained by various techniques such as survey questionnaires or clinical examinations or more informally through personal communications. The technique used is based on the population to be examined. Factors the planner should consider are the number of individuals, the extent and degree of severity of the problem, and the attitudes of the individuals to be surveyed. The greater the number of individuals to be examined, the more formal the survey. If the problem is clinical, as opposed to attitudinal, a clinical examination might be recommended. If the planner wants to interview a small group of individuals on their attitudes and feelings about a particular issue, a personal communication might be more appropriate.
To gather epidemiologic data on the patterns and distribution of dental disease, the planner can use a clinical examination, review patients’ dental records, or consult the National Health and Nutrition Examination Survey III (NHANES III) for data on a population residing in a similar geographic region with similar characteristics.
In addition to assessing the incidence and the distribution of dental disease, the planner needs to inquire into the history and current status of dental programs in the community. Questions to ask include the following: