PICCEP FINAL REPORT · DECEMBER 2003 17

curriculum that focused on provider-patientcommunication. The interactive instruction and smallgroups workshops led participants through techniquesfor recognizing and prioritizing problem behaviors withpatients, identification of where patients fall on the “stagesof change” continuum, and techniques to help patients tochange problem behaviors. In addition, the curriculumaddressed mental health and psychiatric topics ofparticular importance to primary care providers, includingdiagnosis and management of acute psychosis, recognitionand management of depression and anxiety and panicdisorders, and substance abuse and dependence. Theprogram consisted of a total of 12 hours (four hours in2002 and eight hours in 2003) of on-site workshops inall PICCEP sites except Guam and CNMI (where PICCEP

provided specific CCE courses requested by thosejurisdictions).

Participants evaluated all of the behavioral health courses,which were consistently well-attended and received (seebox above).

EVALUATION OF PICCEP CME COURSES (BEHAVIORAL HEALTH TOPICS): 2002-2003

Republic of Palau

Ebeye, RMI

Majuro, RMI

Yap, FSM

Pohnpei, FSM

Chuuk, FSM

Kosrae, FSM4.7

4.8

4.8

4.3

4.8

4.9

4.6

4.7

4.7

4.9

4.9

4.7

4.8

2002

2003

Very good (5)Good (5)Very poor (1) Poor (2) Average (3)

Mean Course Rating (1-5)

Juris

dict

ion

CNMI and Guam received different types of CCE.

PICCEP partner U of HI provided CCE to American Samoa with different evaluation protocol, with same general results.

“Much-needed training and guidance.

This will definitely facilitate my clinical life.”—course participant

SAMPLE PICCEP BEHAVIORAL HEALTHCOURSE TOPICS

• Alcohol problems: screening and brief interventions

• Enhancing patient motivation: Managing chronichealth and substance abuse problems

• Enhancing motivation with diabetes patients (exercise)

• Smoking cessation

• Definitions: Substance abuse and dependence

• Alcohol and tobacco problems: Assessing, interveningand managing patients

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promote awareness of the problem and encouragebasic preventive behaviors, the team looked not onlyto non-dental providers such as physicians, nurses, andcommunity health workers but also to such “auxiliary”providers as directors of Head Start and of public healthand maternal and child health programs. PICCEP dentalfaculty from the University of Washington School ofDentistry developed a series of CCE lectures andworkshops on dental health issues—combining didacticand hands-on methods—that was presented inconjunction with the CME provided by the project’smedical team. The program focused on interventionsfor pregnant women and very young children.

The PICCEP team assembled a packet of oral healthinformation and protocols to be distributed in the Pacificjurisdictions. The PICCEP oral health team emphasizedthe integration of preventive oral health strategies intoprimary medical care, shared preventive techniques suchas the application of fluoride varnishes, and providedinstruction in diagnosis of dental disease, identificationof referral and treatment options, and consultation withdental providers, physicians, and others working withchildren. In response to requests, PICCEP providedtranslations of University of Washington publishedmaterials (including the “Lift the Lip” flip chart), inMarshallese and Kosraen.

The program has raised the region’s awareness of theintegration of oral health strategies into primary care,and some of the jurisdictions have continued the work.Palau, for example, developed a model oral healthprogram that includes an oral health nurse who workswith MCH providers. The RMI has initiated new oral

“Very practical information/application

which are simple but can take care of a very

serious and prevalent problem with children.

Thank you very much for sharing with us.”—course participant

ORAL HEALTH PROGRAMSIn part because some of their faculty hadworked previously in the Pacific Islands, thePICCEP team knew at the outset of thePICCEP that early childhood dental diseasewas highly prevalent in the region. It affectsmore than 90% of the children, a rate morethan double that of the mainland UnitedStates. A survey conducted on Kosrae by alocal dentist in 2002 found only 1 of 123 first-grade children to be free of dental decay. TheIOM report, a review of research literature,and PICCEP site visits identified a generalshortage of dentists and dental health workersin many parts of the region.

But poor oral health has been evident even inareas with highly developed health systemsand large health workforces. The problem isclosely linked to changes in lifestyle that haveoccurred with the shift to cash economies, and byextension, to a diet rich in such “cariogenic” foodsas soft drinks and sugary cereals and snacks. Bottle-feeding behaviors, particularly using sugar-containingsubstances, have further contributed to an outbreakof caries in young children. When children contractthe infection—often from their mothers and beforetheir first birthdays—it spreads rapidly to deciduousand then permanent teeth, causing pain, dysfunction,and demand for expensive (and often inaccessible)dental health services.

To address the problem, PICCEP developed an oralhealth CCE component to train providers in cariesprevention strategies that can be performed in the usualscope of work of primary care providers. The educationand training engaged both dental and medical providersin achieving a common goal of recognizing oral healthas an integral part of general health, and dental care asan important component of primary health care. To

PICCEP oral health demonstration, Chuuk, FSM

PICCEP FINAL REPORT · DECEMBER 2003 19

health surveillance methods for young children. PICCEPalso identified regional individuals who could be involvedin providing oral health CCE to encourage regionalsustainability, and it helped revitalize the Pacific BasinDental Association as an active subgroup under thePIHOA. PICCEP oral health faculty helped severaljurisdictions prepare successful grants to CDC for oralhealth programs in the region. Several dentists from theregion have attended the University of WashingtonDental School Summer Institute.

The PICCEP oral health program faculty participatedin many regional planning and policy forums, includingthe Oral Health Summit held by the South PacificCommission, WHO, and a meeting with the dentalprogram leadership of the Fiji School of Medicine (wheremany of the region’s dentists are trained) in early 2001.

The program stressed the importance of integratingoral health into the larger system of primary care andinvolving medical personnel in anticipatory guidanceand preventive services.

“Eye-opening remarks on practical things

that can be done with very low financing;

very practical–maybe we

need to implement urgently.”—course participant

HEALTH ASSISTANT PROGRAMSMembers of the PICCEP team who had worked indeveloping countries knew that much of the healthservices provided in the remote locations of the Pacificjurisdictions do not occur in the central hospitals butin more remote clinics and dispensaries staffed by non-physicians. In many locations, these staff are healthassistants or health aides who have had minimal clinicaltraining. Some Pacific states have adopted the healthassistant or health aide model, in which villages orremote communities select lay members to receive basicclinical protocol training to handle emergencies, providebasic preventive and prenatal care, and treat commoninfections. This often occurs under radio or telephonesupervision by centrally located physicians or otherclinicians. The Alaska Health Aide Program, whichbegan in the 1950s, is one example of the successfulapplication of the health assistant model. The Universityof Washington physician assistant training program(MEDEX Northwest) has a strong relationship with theAlaska program, including the training of more than 30health aides as physician assistants.

Drawing from its Alaska experience, MEDEX developedand implemented a health worker program in FSMduring the 1970s. Health worker programs are in placein Yap, Chuuk, and the RMI, operating with varyingresource, infrastructure, and training needs.

As part of the program needs assessment, MEDEXstaff during 2002 visited the RMI and FSM (Chuukand Yap) to assess continuing education for the healthassistants. They found, to different degrees, a poorlymaintained primary care system, one further underminedby factionalism and nepotism. The over-riding problems

appeared to be deterioratinginfrastructure, the lack of evenradio communication in manyareas, and a dearth of resources totransport both clinicians and suppliesto remote islands.

PICCEP sought new resources tomobilize MEDEX to create andimplement CCE and additionaltraining for health assistants in theregion, a proposal that generatedstrong interest in several jurisdictions.It called for application of a “trainthe trainer” model, through whichMEDEX staff would train physiciansin Chuuk, considered the mostchallenging and needy environment

PICCEP course, Ebeye, RMI

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in the region. The physicians would become familiarwith the health worker system, engage in curriculumdevelopment, and deliver month-long CCE to healthassistants. These activities could be duplicated anddelivered in other jurisdictions over time.

To prepare for this effort, PICCEP in 2002 broughthealth assistant program educators from Chuuk toAlaska to observe training and operations of the Alaska

Health Aide program, which trains lay communitymembers to provide, under physician direction, basichealth services in remote sites. But 2003 was to be thefinal year of the PICCEP program because HRSAdecided to have a new competitive cycle to award CCEfunds for the Pacific jurisdictions. The health assistant“train the trainer” program requests were not fundedby HRSA or others.

Pohnpei, FSM