A learner-centered global oral health education approach

The survey tool

During Phase I, a validated global oral health survey [Table 1] was administered to dental students and recent graduates (learners) exposed to the charitable dental missions. This questionnaire consisting of 21 items that included the demographics was powered in Qualtrics [Table 1].^[2,6] The global oral health-related questions were linked to the curriculum content of the global oral health course as described by Karim et al.^[2] During this phase, we examined our dental learners’ existing opinions and knowledge of global oral health for those students who had completed global oral health mission trips.

The didactic planning

The information from Phase I was used to create a training module for dental students as a global oral health plan (Phase II) that included service-learning and social determinants of health (SDH). The ultimate aim was to formalize training in global oral health and prepare dental students for international community service-learning while equipping them with a basic global oral health understanding.

The module preparation and design

Developing curriculum for global oral health, training focused on determinants of health is a component of Global Health Competency domains. This domain addresses social, economic, and environmental factors that determine health, and that health is more than the absence of disease.^[7]

Key findings from the Phase I survey were instrumental in designing the interactive SoftChalk^[8] module. The module, titled Global Oral Health Plan, trained students in global oral health topics, global health systems, and addressed their knowledge gaps as identified in the pre-survey. Efforts were made to ensure that the module did not duplicate existing curricular content. As a result, a student-centered elective was created to include primary oral health-care principles and the Basic Packages for Oral Care (BPOC).^[9] Global evidence-based practices were emphasized using upstream preventive approaches connecting student interest to a meaningful experiential global oral health service-learning. The module introduced topics including global oral health, oral health inequalities, and resources, primary oral health care. It included the BPOC component of the WHO global oral health programs,^[9] affordable fluoride toothpaste,^[9] atraumatic restorative treatment,^[9] the role of World Dental Federation (FDI), NGO or Non-governmental Organizations, with an emphasis on global health volunteer immersion.^[10] The module also focused on cultural adaptation and equitable delivery of oral healthcare during global oral health exposures.

All components of this pilot study were determined to be exempt from the Institutional Review Board oversight by HSC20180542N as Global Oral Health Education from the Dental Student Perspective: An Educational Module.

Participants

Thirty-two dental learners (Female = 18 and Male = 14) and learners who had attended mission trips to Jamaica and the Dominican Republic in 2018 and 2019 were invited to complete the pre-survey. They included two freshmen, five sophomores, six juniors, 12 senior students, and seven recent graduates as current residents as learners.

Twenty-seven learners completed the initial survey (same as pre-survey) in its entirety. About 74% (20/27) had previous global mission trip experiences and 26% (7/27) had not. Of the 20 who had previous exposure to global mission trips, 80% (16/20) had 1 week of exposure, 10% (2/20) had 2 weeks of exposure, and 10% (2/20) had between 2 and 4 weeks of exposure. About 41% (11/27) were not aware of developed and developing countries’ oral health-care systems [Table 2]. Global oral health pre-questionnaire indicated that the students surveyed perceived their present dental school training has not prepared them to understand global oral health. About 56% (15/27) reported a lack of cultural competence training in addressing international oral health issues. About 52% (14/27) were not aware of the global health ethics. About 59% (16/27) did not know what constituted the Basic Package of Oral Care,^[9] and 56% (15/27) did not understand the primary healthcare strategies of equity, prevention, community participation, appropriate technology, and intersectoral approaches. About 81% (22/27) did not realize that the FDI is the world’s primary oral health NGO. About 74% (20/27) did not know that FDI facilitates the exchange of information across borders to encourage optimal oral health for all people.

Outcomes

During the Phase III, 12 dental students completed the module, pre-care training before their trip, and post-care evaluation after their Jamaica, Dominican Republic mission trips or the Ethiopia Global Oral Health Outreach (M = 5, F = 7). Before this training, dental students surveyed did not know which organization is the world’s leading oral health non-governmental organization [Table 2]. The post-questionnaire survey analysis with a Wilcoxon signed-rank test did not yield statistical significance; however, the medians for both scores increased from pre to post despite not being statistically significant [Table 3 and Figure 1].

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Figure 1:

The participant’s knowledge and attitude score differences between the pre- and post-survey (n=12).

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It is noteworthy to highlight that participant dental students (56%) expressed limited global cultural competency. They also expressed the lack of global health ethics (52%) awareness (knowledge). At the same time, they agreed that cultural competence training (89%) and awareness of global health ethics (96%) are essential to address international oral health issues (perception). At a minimum, this educational global oral health design provided the participant dental students with opportunities to learn about global communities and a chance at gaining knowledge and insights into the utilization of a global community service-learning model.

Recommendations

We recommend an upstream global oral health education model with a focus on poverty and health literacy related to poor oral health. There is a strong need to develop future oral health practitioners to treat the underserved global populations by creating international community-based learning opportunities for them. International exchange programs that provide field experiences in developing countries and underserved areas of the world (1) foster global oral health advancements and (2) promote an appreciation for cultural diversity and socioeconomic disparity in the communities that dental graduates will be serving.^[13]

We propose an education model to focus on global cultural humility training, the impact of SDH, and health literacy related to poor oral health. Since community-based learning is expanding globally to offer dental students opportunities for international experiences, we aspired to add global oral health community service-learning training at our institution [Figure 1]. It was essential to teach an immersive global oral health approach to preventive oral health care, as compared to mission trip approaches that mainly focus on urgent clinical treatments.

Limitations

This pilot study’s limitations included a small sample size that decreased statistical power and generalizability. Participant students also had a high level of interest in the topic and, therefore, served as a convenience sample. To better assess the impact of the module based on present results, efforts need to focus on a more comprehensive student evaluation and larger number of participants in subsequent years.