The Bila Muuji Oral Health Promotion Partnership

Bila Muuji Aboriginal Health Service Incorporated (Bila Muuji) is a regional grouping of Aboriginal Community Controlled Health Organisations (ACCHOs) in western New South Wales (NSW). It was established in 1995 and now has seven active member ACCHOs in the locations of Bourke, Brewarrina, Gongolgong, Walgett, Coonamble, Wellington and Orange. Bila Muuji means ‘river friends’ and Bila Muuji’s vision is to provide collective support to its members and to identify and address shared issues impacting on Aboriginal communities across the region.

In 2006 Bila Muuji members identified poor oral health and lack of access to dental services and advice as major priorities for western NSW Aboriginal communities. There were very few dental practitioners in the region, and patchy activity in oral health promotion programs. The more remote towns of Bourke, Brewarrina, Gongolgong, Walgett and Coonamble had no fluoride in their water supplies. Health checks conducted in 2004 by the then Far West Area Health Service found that in some remote Bila Muuji communities, 5–6-year old children had on average 7.56 primary (or baby) teeth affected by dental caries (decay) (unpublished data). This was eight times greater than the state average for that age group.¹ The percentage of 5–6-year olds with no caries in their primary teeth was as low as 5.6% compared with the state average of 69%.¹ Caries in the permanent (adult) teeth of children in the 11–13-year age group was up to five times the state average (unpublished data).

While there were no oral health data specific to the adult population in the majority of the Bila Muuji communities, a national survey of adult oral health conducted in 2004–06 found that the Indigenous adult population had 2.3 times more untreated caries than the non-Indigenous adult population, and 57% of Indigenous adults had one or more teeth affected compared with 25% of non-Indigenous adults.²

Aboriginal and Torres Strait Islander people have also been identified as a priority population in the recently developed Oral Health 2020: A Strategic Framework for Dental Health in NSW.³

In 2006, Bila Muuji members developed a service plan to address the poor oral health status and low level of dental services in the region. This plan identified the need for a regional dentist position and a regional oral health promotion program. Due to limited availability of statewide funds, the regional dentist position was not funded however funds were made available for the oral health promotion program – including a full-time coordinator – through the Centre for Oral Health Strategy, NSW Ministry of Health. In 2008 a formal partnership was established with the then Greater Western Area Health Service (GWAHS) to support the program.

The first step was to work with frontline staff within the ACCHOs. If the Bila Muuji Oral Health Promotion Program was going to have strength and longevity it had to be embedded within the communities, with ongoing support and commitment from staff at the ACCHOs.

Two workshops were organised in 2008 with the overall aim being to identify and implement oral health promotion priorities and activities across the Bila Muuji region. Participants were largely Aboriginal Health Workers and oral health staff from Bila Muuji member organisations, with some GWAHS staff also in attendance.

The first workshop was held in Sydney at the Centre for Oral Health Strategy. Information sessions were provided on dental diseases and their causes, principles of prevention of dental diseases, examples of oral health promotion programs, and approaches to oral health promotion both on an individual and a community level. Representatives from the dental profession and dental industry delivered the presentations and participants were given opportunities to share information on oral health and related issues from their communities. At the end of the workshop participants were given a formal task to identify oral health problems in their community, using a task sheet that guided them through the necessary steps. Then, in discussion with co-workers and others, they were asked to identify oral health promotion activities to help address these problems.

At the second workshop held 3 months later, the participants shared the knowledge they had gained regarding oral health problems in their communities and some of the factors impacting on the planning and implementation of oral health promotion activities.

There were several common issues identified within the participants' communities:

• a general lack of knowledge about ways to prevent dental disease

• lack of dental services

• high consumption of sweet drinks in baby bottles, particularly cola drinks

• the importance of encouraging the drinking of water, and for school children to have water bottles filled with fresh water while at school

• poor access to dental information resources

• the importance of maintaining communication networks.

Some of the activities that had been initiated by participants, in association with relevant health personnel, in their communities included:

• supervised toothbrushing with fluoride toothpaste at school breakfast clubs and in preschools

• providing oral health information and advice to young mothers’ programs

• incorporating oral health checks into Healthy for Life programs and organising appropriate follow-up dental care.

At the second workshop participants used their knowledge and experiences to work together on an implementation plan for the regional oral health promotion program, guided by Bila Muuji’s oral health advisor who had been working with Bila Muuji since 2006 to improve oral health services in the region.

The oral health promotion implementation plan identified certain target groups such as children aged under 5 years, school-aged children, young adults, people with chronic disease, and the elderly. The plan detailed aims, strategies, measures, necessary resources and funding, and identified those with responsibility for the various activities. These activities included: instituting school-based daily toothbrushing programs; delivering oral health information sessions to the target groups; training ACCHO health staff in ‘See My Smile’, a program designed to assist non-dental workers to identify early signs of dental caries in young children; encouraging the drinking of water by distributing water bottles at schools and by providing sippy cups to young families; and providing oral health information to the staff of chronic disease programs.

The partnership with the then GWAHS enabled the employment of a regional coordinator for the program. GWAHS provided some funding for the position, as well as administrative support and office space in Dubbo for the coordinator. Bila Muuji received further funds from the Centre for Oral Health Strategy to fully fund the position. In 2009 Bila Muuji developed a Memorandum of Understanding with Charles Sturt University. This included a scholarship scheme whereby Bila Muuji would support selected undergraduate Bachelor of Oral Health students, with the intention of introducing the students to oral health issues in rural Aboriginal communities, and encouraging them to work in these areas upon graduation.

In 2009 a regional oral health promotion coordinator was appointed. The position was based in Dubbo, with travel to the Bila Muuji communities on a regular basis to support and progress the activities already established by the ACCHO staff. The existence of a well-developed implementation plan was of assistance to the coordinator, giving direction and providing insight into the issues faced in the communities. Added strength in the plan was its ‘ownership’ by Bila Muuji members.

Guided by the priorities identified in the oral health promotion plan, the regional oral health promotion activities initially focused on children aged 0–5 years, young mothers/carers, and school-aged children. The young children and mothers/carers were accessed largely through young mothers’ groups and preschools. Working with ACCHO staff in each location, the regional coordinator provided oral health information and resources relevant to these groups on a regular basis, and also supported the ACCHO staff to take the lead in future programs such as school-based toothbrushing programs.

The toothbrushing programs are for all children attending the schools, Aboriginal and non-Aboriginal, though the targeted schools have a large percentage of Aboriginal children in attendance. The coordinator and local staff provided guidance and resources for the toothbrushing programs including printed information about program protocols, toothpaste, toothbrushes and toothbrush holders. A professionally produced support manual for school teachers is currently near completion.

The oral health promotion activities of the Bila Muuji regional oral health promotion program are supported by evidence-based literature.⁴ These interventions continue and have become embedded in the routine activities of local ACCHO, health, and community staff. The program is now shifting focus to young adults and people with chronic disease, and formal evaluations of the programs are being planned. These will examine issues such as participation rates in the programs, appropriateness of information and interventions, staff involvement, improvements in oral health practices, and areas for overall program improvement.

Improvements in oral health will occur slowly, provided there is sustained community-based effort and support from all sectors. Oral health and health practitioners are not necessarily able to influence the social determinants of health that impact on the lives of Aboriginal people in rural and remote communities. However, through coordinated efforts and understanding they can continue to provide appropriate interventions that will contribute to oral health improvement. In the case of the Bila Muuji oral health promotion program, its acceptance and growth in communities has been driven by the inclusion of local staff from the beginning, and the active participation of partners such as the Local Health District. Annual workshops provide ongoing professional support and updates to staff, most of whom participated in the initial workshops in 2008. The profile of oral health has been raised and coordination with other health and community program areas has increased. The importance of working with local community staff, in a meaningful sense, cannot be stressed enough.