Aboriginal leadership is essential for scaling up strategies to prevent dental disease 

The Poche Centre for Indigenous Health, University of Sydney
Authors (L-R): John Skinner, Boe Rambaldini, Yvonne Dimitropoulos, Tom Calma AO and Kylie Gwynne. Poche Centre for Indigenous Health, The University of Sydney.

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ACTIONS FOR POLICY AND IMPLEMENTATION

  • Policy makers need to consider appropriate funding and scale-up strategies for evidence-based strategies included in state and national plans to address Aboriginal and Torres Strait Islander health issues.
  • Funding and workforce training models need to be re-considered and adapted for population prevention strategies such as school-based fluoride varnish programs.
  • Evaluation measures need to be balanced against their impact on scale-up and implementation costs.

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RESEARCH CONTEXT

While National and State oral health plans and strategies include the scale-up of fluoride varnish programs, particularly for high-risk populations such as Aboriginal and Torres Strait Islander children, limited progress has been made.  In NSW, a pilot school-based fluoride varnish program specifically developed specifically addressed the National Oral Health Plan and the NSW Aboriginal Oral Health Plan. Subsequently, we also undertook a process of co-created research with key partners to look at how we could use Aboriginal dental assistants to apply varnish and to have a routine school-based program of four applications per year based on the NSW school terms. A small rural pilot was devised with a grant from the Sydney Policy Lab at The University of Sydney in 2017 and then followed up with an urban pilot with a MRFF grant in 2019.

These pilots led our research team on an implementation journey which included piloting the use of Aboriginal dental assistants to apply fluoride varnish and advocating for this to be supported by national policy change by the Australian Dental Association. Further advocacy with the Commonwealth Department of Health led to a submission to the Fourth Review Dental Benefits Act Review in 2019 and a national costing paper to demonstrate how a scaled-up program could be funded under the Child Dental Benefits Schedule.

The interest generated from this engagement and research led to substantial national interest from academic, policy makers and health care professionals. To share knowledge and ideas the Poche Centre has hosted two national fluoride varnish workshops. These have led to further collaboration between Jurisdictions and has also encouraged further scale-up in the absence of policy leadership from the Commonwealth. With our partners in academia, government and in the related professions we have sought to identify and address implementation barriers. This work has led to greater interest in co-translation of this evidence-based strategy from policy into practice. Importantly co-produced research has been undertaken at key steps along the way with our partners which in turn has led to further scale-up where local Jurisdiction resources are available.  

We have found that even when a well-proven and evidence-based prevention strategy is included in various state and national plans there can remain substantial barriers to scale-up. At the numerous meetings we have attended over the past seven years several common reasons for not implementing this previously agreed strategy include:

  • Some clinicians wanted more evidence of effectiveness – could we do one more study?
  • In-built evaluation measures were wanted that would make it non-scalable due to the additional cost burden.
  • Why not just use a clinical service (instead of prevention) as it’s “safer”?
  • Lack of priority given to Aboriginal oral health
  • Racism – Aboriginal people are not seen as experts because they don’t have a dental degree or PhD, regardless of the wealth of cultural and community knowledge

One of the main reasons we have been successful in this work is that we have two engaged Aboriginal leaders and Elders who understand where fluoride varnish fits in the wider health research and policy environment at the state and national level. It is vital to have leaders who can represent the needs of the community for evidence-based initiatives against a background where there is often political, professional and academic inertia.

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