13 . SHCXRT - AND

BND BISOURCES * LONG - TZ'GI OBJETIVBS I N 3mAL PBOGW PUNNING -

WHICH AFFZCT THE DET?BXIIJATION OF P R O G W OBJECTIVES

John W. Stone, D.D.S . , M.P.H, Michigan Department o f Health

Four of the most popular terms of the jargon of the public health profes- sione are 'lob jec tiTes,II lfreaources,'l llprogram-planning,ll and ttevaluation." These terms are not unique t o public health, but rather the dynamic nature of public health demands constant expenditure o f effort t o determine desira3le objectives and the most effect ive resources by which they may be attained. Hence, program-planning ani! evaluation a re public health endeavors which never cease.

This presentation has as its purpose a review of those r9sources which w i l l a f fect the determination of the objectives when planning a program of dental public health,

Planning a progran requirea a systenatic analysis of the groups and organ- i z a t i ns that may be iavolved as part ic ipants in the program under considera- tion. reeources available to the planners of the program, may be grouped into two additional categories. phy 8 ical r esourc G 8.

f Such groups and organizations const i ta te tho personnel sectoi' of the The remaining resources

They are the financial and the

For th i s presentation the term llresourcasl' r e f e r s t o the means available for the implementation and conduct of the proposed program, and tlobjectivesll means the ultimate goala being sought through t i e program,

I n addition t o these resources there a re other resource fac tors which must be considered at the time the objectives of the program are being determined, The existence of tho problem must be recognized; otherwise there would bo no j u s t i f i ca t ion for the program, But the mere recognition o f the existence of the problem is insufficient--there must be a determination of the extent of the problem.

I t i s impossible t o evaluate properly the resource8 which a r e available without a delineation of the extent of the problem, by which the extent o f the problem may be determined. i s a thorough examination o f every member of a universal population. impracticality of such an examination i~ apparent, I t would be expenoive in both timo and money, and the resul tant data would be so'bulky that e f f i c i en t summarization would bo a tremendous taek. has stimulated the development of aurvey technics fo r col lect ing data,

T h e r e are several methods The most obvious method

The

The recognition of these obstacles

Any surwy may be characterized as a comprehensive c r i t i c a l inspoction t o provide exact information concerning a specific condition or i t s prevalence.

*Presented at the American Public Xealth Association Meeting, Kansas City, Mo, , Rovember 17, 1955. (Dental Section)

Surveys are widely employed by public health workers and are deeigned t o secure selected items o f information at the time the information is col ected on condition8 i n a group o r a representative portion o f the population.' The survey is not, aad should not be, an end i n i t s e l f , If the purpose is t o assemble useful information for reference by anyone who cares t o consult it, then the survey should be so planned and conducted. I f i t i s t o be par t of a program of act ion, then it sh l d be 80 oriented, and only the essent ia l material ehould be solicited.f' After the information has been collected, it must then be c lass i f ied , tabulated, summrized, and interpreted, Upon comple- t i o n of these f ive steps w i l l depend the determination of 5be extent o f the problem and from t h i s determination a notion of the possible methods by which the condition may be rodwed o r removed,

There i s a tend ncy for dental public health workers t o use the phraso "unmet dental needett3 as often and as carelessly a8 they use the terms "resourcestt and "ob jectives.tt revealed the near universi ta l i ty o f the dental diseases. With the possible exception o f the common cold and eruptions o f the skin, dental car ies occurs more f;-equent1.y in a papulatioa than any other $isease entt ty, Dental caries a f fec ts nicstx-f ive per cent of the population, Additional studies indicate that he th9r dental diseases may have an equal, o r a nearly equal, distribu-

Scient i f ic surveyn alrd f ielrl. studies have

t ione$ , 18, 13

There i s not a pract ical method available by which i t is possible t o determine the proportion o f the dental need which remains untreated. is, in f ac t , no val id reason a t t h i s time t o attempt t o gather t h i s informa- tion. The dentist-patient ra t ioe aa coxpated 3y the Bureau o f Eaonomic Research and Statistics of the Amerlcan Dental Association7 are prima facis evidence tha t i t i s impossible for the dent is ts who are a t presenCJ in practice t o provide complete dental service f o r the t o t a l population i n their reapeo- t iye areas, health t o think i n terms of m e t dental needs which may either be prevented o r treated through community programs, hinge the formulation of tho objectives of any program of dental public health,

There

I t behooves a l l persons engaged in programn of dental public

Upon the recognition of t h i s fact w i l l

The a t t i tude of personnel i n public hoalth, in the dental profession, and the public w i l l determine, i n a large rnoa8uT8, the succees of any program of dental public health. The importauce o f the goal8 of the program must 'be clearly understood by a l l full-time and part-time public health workers. Inasmuch as modern public health has a8 its purpose the improvement of the health conditions of the community in which it operates, i t requires the cooperative action of the persons of the various disciplines within the scope of health aervice.

In order that there may be a unified prog-ram, the personnel in each of the ac t iv i ty areas must be apprised of the primary, or long range goale of the organization of which they are a part. The wholehearted support for a program of dental public health by the non-dental members of the staff of the public health organization w i l l be missing unless they have an understanding of the basic tenets o f the practioa of dentai public health,

Unfortunately there rensain a few persona i n the professions of public health who do not recognize dental programs as a valid public health activity,

As the r e su l t of improved relat ions, increased understanding, Etnd a broadening of profesaianal outlook such attitudes are on the waneo are entering public health must re-focua their a t tent ion from the individual 88 a patient t o the community as a patient.

Dental personnel who

The ultimate consummation of almost every program of dental public health occurs in the off ices o f the private dental practitioner. understanding and support of the private practi t ioner must be obtained; other- wise the euccesa of the program w i l l be placed i n Jeopardy.

The sympathetic

The a t t i tude of tho public muet be such that it w i l l accept its responsi- b i l i t y in assis t ing i n bringing about the succeesful completion o f the program.

The nature of the program t o be in i t ia ted w i l l depend upon the pereonnel available, or potent ia l ly available, f o r i t s operation. Tho first s o u p which must be considered is that group which includes the dent is ts and dental hygienists who are already act ive i n the f i e l d of public health, I t is impos- sible t o ascertain the exact number i n th ia group because of the administrative atruc ture of the organizations operating, o r sponsoring the operation of programs of dental public health, No central rogter of public health dent is ts and dental hygienists Is maintained, I t is necessary, therefore, t o seek the information concerning these profeeoions f r o m various divergent sourcea.

I t could be said that every dent is t and dental hygienist who is rendering service t o the public 5s aotive in public health f o r they are improving the health of the community. However, the American Dental Association l ist 157 members for the year 1955 who are c lass i f ied as public health dentists.' The United States Public Health Service report of local personnel resource8 f o r the year 195ZL1 reported that a t the local l eve l there was a t o t a l of 37,036 persons i n a l l categories employed by official health agencies. there were 234 dent is ts and 388 dental hygienists, I n addition t o the of f i c i a l health agencies there were 8,695 persons employed in full-time health ac t iv i t i e s by other o f f i c i a l agencies, such as departments of education and departments of welfare. programs, approximately 356 dent is ts and 771 dental hygienists who were actively engaged in programs of public health dentistry. The information contained in tho pub- l i ca t ion w a s derived from the reports of the various full-time health unito receiving federal assistance, and f rom the full-time uni t s receiving no assist- ance but wishing t o report nevertheless. amounted t o s l igh t ly less than f ive per cent.

O f the to t a l

There were 122 dent i s t s and 383 dental bygieniajta engaged in these I t may be calculated that as of December 31, 1952, there were

The percentage of nonreporting units

The inportance of cooperative action i n programs of dental public health cannot be over-emphaeieed. persons o f other than the dental profeseion have a significant responsibility in helping t o reach the goals being sought through the program, Dental public health i n i t s broadest scope cuts across the areas of ac t iv i ty and interest of every other discipline o f public health. personnel are the only members of the o f f i c i a l public health staff who w i l l be

The complexity of the programs requbes that

While in most instame8 the dental

devoting their t o t a l working time t o programs of dental public health, the potential assistance of the other professions must not be overlooked, Each o f the professions i n public health has contributed some of i t s member8 t e dental programs. The nurses, health educators, engineers, and laboratory personnel have been uti l ized mos t often. On December 31, 1952, there were some 12,492 nurst38, 272 health educators, 407 enginffrs, and 1,301 laboratory pereonnel employed in local health organizations, Combining the approximate t o t a l of dent is ts and dental hygienists in full-time public health with the members of the other professions employed in local health uni t s , i t may be assumed that on December 31, 1952, there were some 15,599 full-time public health personnel

-who were available, ' o r potentially available, for programo of dental public health,

!!Every act performed for the promotion of public health involves an expenditure of money, whether it be f o r supplies, f o r transportation, o r f o r the ealar ies of personnel, public health program is determin d i n the f i n a l analysis by the amount of

In fac t , the very nature and extensivenesg of the

funds available f o r i t s conduct," 8 There are three major sources of funds f o r the operation of program6 of

dental publio health, The source8 are the agencies of the federal government having an interest i n health, s t a t e agencies having similar interesta , and local agencies,

Federal funds f o r the promotion of public health come from two separate but re la ted functional unite of the Department of Health, Education, and Welfare, Bureau.

They are the United States Public Health Service and the Children's

There has never been a categorical grant of funds from ei ther the Public Health Service o r the Children's Bureau for the in i t i a t ion or conduct of programs o f dental public health, The federal funds which have been used f o r dental programs have been, f o r the most par t , derived f rom the General Health grant t o the s ta tes o r t e r r t t o r i ea , o r f r o m some other categorical grant f o r programs having dental implications. grants-in-aid t o the s t a t e from which funds may be derived f o r the operation o f dental programs; the grants are f o r maternal and child health and services f o r crippled children, There are f o u r grants f rom the Public Health Service which have dental implications. Statee, General Health," the12thers are cancer teaching grants, research grants , and training grants.

The Children's Bureau provideo two

The first is the grant f o r "Assistance t o

State and local appropriations f o r programs of dental public health may be either categorical or as a part of general health funds, The position o f the dental uni t in the administrative hierarchy oftentimes determines the 8ase o r d i f f icu l ty with which funda are obtained,

The nature of the program w i l l determine the physical res6urce8 which must be available, or lpotentially available f o r i ts implementation. z'e80urce8 includes the equipment, materials, space, and transportation necessary for the o p r a t i o n of the program. The requirement8 w i l l vary with the program, and often the requirements w i l l change aa the program progresses.

Physical

Programs of

dental public heal th which are primarily educational w i l l require printed materials, poeters, displays, films, and other informational devices. I n addition there muat be a consideration of the off ice spaco requirements of tho program. Included must bo 853 appraisal of the space available, tho telephone service, the u t i l i t i e s , and the custodial services available, pointed out that no matter w h a t the nature of the program, there w i l l be a space and "house-keeping" aspect which must be considered and resolved i n order that the program may operate,

I t may be

Those programs in which dental care is to be provided w i l l require dental equipment in addition t o the heal th educational material and the space require- mente, acquired. budgetary channels. o f f ic ia l o r non-official agencies, o r through the combined e f f o r t s o f o f f i c i a l and non-o f f ic ia l agenc i e s .

There are several methods by which the necessary equipment may be Off io ial agencies may purchase dental equipment through regular

Another method i s through the cooperative e f fo r t s o f e i ther

Dental operatory equipment has been recommended to be included in the f a c i l i t i e s constructed u d e r the federal H o s p i t a l and Medical F a c i l i t i e s Survey and Construction Act. The modification of the Act 50 includd diagnostic and treatment f a c i l i t i e s has renewed in te res t i n the dental aspects o f the program, I t has been proposed that mobile dental c l i n i c equipment be included in the f a c i l i t i e s of the diagnostic and treatment centers. The off ice of the program director offered tho following opinion:

I'We find no basis in the Act o r Regulations fo r approving a 'mobile' diagnostic or diagnostic and treatment un i t a8 an e l ig ib le 'project ' under Par t C o r Par t G of the Act. I t might be possible, however, to consider such a uni t as i n i t i a l equipment for an approvable project and t o include its oas t as e l ig ib l e f o r federal participation, Any such request would, of course, have t o be con- sidered in re la t ion t o the f a c i l i t y planned and i t would have to be demonstrated that the program of the f a c i l i t y j u s t i f i ed the inclusion of such a mobile pit as i n i t i a l equipment necessary f o r the operation o f the fac i l i ty . "

Programs of dental car ies prevention through fluoridation of community water supplies muet include a consideration of the i n i t i a l cost of the flwri- dating equipment as well as consideration o f the cost of i n s t a l l a t ion and o p e r e t ion of the feeders,

D I SC US S I ON

Unlike some of the other diseaaes, there i s no national voluntary organiza- t ion dedicated to the eradication of the dental disease8. organizations, o f f i c i a l health agencies, and f ew c iv i c organizations such as the P i l o t Club which have been act ive i n programs of dental public health for many years, but the magnitude of the problem appears t o be undiminished in spite of a l l the e f fo r t e which have been expended. I t i e true that the advent of f luoridat ion of the community water s u y p l b s and the topical applications of sodium fluoride solution t o the teeth of children in selected age groups have

There are professional

revealed a significant reduction i n the incidence of dental car ies , as well as an attendant reduction i n the conditions which are normally eequlae of untreated dental caries. concomitant reduction in the prevalence or incidence o f periodontal disease, malocclusion, or any of the other dental pathoees which are not d i rec t ly the resu l t of the carious process. A s discouraging as this fac t may be, i t does not disparage the work which ha8 been done in behalf of improving the dental health of the nation. The fact j u s t emphasizes the immensity of the problem and the meager force which has undertaken the destruction of dental disease as a blight on the public 's health. remediation are the weapons of choice i n the ba t t l e againat dental diseaae, but the i r effectiveness i s direct ly proportional t o the resources u t i l i zed i n the operation of the program.

It i s also true, however, that there has been demonstrated no

The weapons of education, prevention, and

How, then, may the programs be made more effective? The anewer l i e s in the real izat ion that in every community there are usually many untapped sources of support and assistance f o r programs of dental public health. is the responoibility of those persons who must organize and operate a program of dental public health t o e f f ic ien t ly u t i l i z e the resources at hand in their e f for t s t o looate and incorporate into the program undetected resources which w i l l afford the organization of a t ru ly comprehensive program--a program of greater breadth and depth, and thus a program which has the aseurance of greater effectiveness.

I t

Undetected sources of support and assistance f o r programs of dental public health are usually found in the c iv i c groups and organizations in the community. Almost without exception these c iv ic groups have as one of the i r primary pur- poses the promotion of be t te r health f o r the community. Oftentimes these interests in health are directed toviard some partioular disease or some complex o f s i m i l a r disease en t i t i es . I t may be erroneously assumed that a stated interest in the promotion of a program f o r the reduction of the effecta of some particular disease precludes an interest , o r the poss ib i l i ty of stimulating an interest i n the problems of dental public health. of dental car ies w i l l assist i n securing sympathetic attention to any proposal f o r the effective reduction of the incidence of dental car ies and tho other dental diseases. Community health education can be effective in stimulating the peoplo of the community t o think in terms o f promoting a program of com- munity dental health. and organizations must be similarly oriented in order that there w i l l be a minimum of l o s t motion between the upsurgo of interefat i n such a program and the actual i n i t i a t ion of the program.

The near univers i ta l i ty

The thinking of the public health and professional groups

A resource which i s often completely overlooked o r poorly u t i l i zed i o the resource of the dental pereonnel i n practice i n the community. The personnel of dental public health have been shown t o be inadequate in number t o operate a comprehcnsive dental program. I n sp i te of the protestations evoked by th io statement, it is nevertheless a fact that the magnitude of the dental health problem haa not decreased significantly since the first p r o e m of dental public health was begun. I t would appear then that the combined and coordinated e f for t s of a l l the dental personnel in a community would be more effective in overcoming the problem than the desultory manner of practice usually seen at th i s time. The coordination of the rugged individualiets, the dental peruonnel,

19.

is a thankless task, but the r e su l t s w i l l more than Just i fy the discomfiture result ing f r o m the effort .

The promotion, in i t ia t ion , and operation of a program of dental public health offers a constant challenge t o the proponents of the program. A fac tor which ordinarily may o r may not be envisioned a8 a r e s o u r c ~ i e "know-how." The sum of technical knowledge and experience and administrative ab i l i t y may be characterized as nknow-how.fi To be truly effective, however, llknow-howl' must be tempered with common eense, Inasmuch a8 each community i e similar t o , yet differe from, a l l other communities, it fo l lows then, that eaoh community dental health program w i l l be s i m i l a r t o , ye t differ f rom, a l l other such programs, lishment or operation o f a program of dental public health. f e r r e t out undiscovered raaomes and the of integrating the hotero- geneoua groups and individuals into a functioning osganization sponsoring and operating a program o f dental public health is the mark o f a successful public health administrator, Thus the determination of the short- and long-term objectives i s dependent upon the detection, evaluation, eelection, and ut i l iza- t ion of the resource8 which are available o r potentially available f o r the operation of a program of dental public health i n the community.

Unfortunately there is no set pat tern t o be followed in tho setab- The ab i l i t y t o

In summary then:

The systematic analysirr of the resourcee available o r potentially available i n the community w i l l determine the objective of the program of dental public health t o 3e init iated.

The resource o f personnel w i l l include a l l of tho professional and civic groups and individuale baving an interest in improving tho health of the communiC,y by improving the dental health of the popula- tion.

The number o f dental personnel who are already in practice i a insuffi- c ient t o meet a l l of the accumulated or the incremental dental neede, Therefore, a program of prevention i a essential if inroado are t o be made i n tho effects of dental disease.

The f inancial and physioal resources are dependent upon several f a c t o r s which ham not been elaborated upon, exoept t o indicate the possible sources of these factoro,

There is a constant challenge before the administrator of a program of dental public health to seek out undetected teeources and t o integrate them with the known resource6 in order that the comprehensive ob;lectives of the program may be realized at an ea r l i e r date and with minimum e f fo r t .

CONCLUSf ONS :

1. The dental disease8 consti tute one of the most universal health hazards which haraasee the population o f tba world.

2, Remediation alone hae not been effect ivs i n controll ing the prevalence or the incidence of the dental di8ease(~.

3, Effective control is dependent upon program8 of education and preren- t ion as well as remediation,

4, The community program of dental public health is a device which baa been proven t o be effective i n reducing the ravagea of the dental diseases.

5 . Successful community programs of dental public health depend upon the detection and the e f f ic ien t u t i l i za t ion of the resource8 available or potentially available in the comhunity.

6 . An improvement in the dental health of a community will result in a concomitant improvsment in the general health of the population.

BIBLIOGRAPHY

1. Hanlon, J. J. Principles of public health administration. St. Louio, ~ o ~ i b y , 1950, 506 p. (P. 265)

3, Klein, Henry, and Palmer, C. 1. The dispar i ty between dental need and dental care in echool children i n Hagerotown, Md., and emirone. Am. Dent. A. J. , 38:1489-98, Sept, 1941,

4. Klein, Henry, Palmer, C. E., and Knutson, J. W. Studies on dental caries. I, Dental s ta tus and dental needs of elementary btchoo’l children. Pub. Health Rep,, 53: 751-65, May 13 , 1938.

5. Enutson, J. W , Surveys and the evaluation of dental programs. p. 65-91. ( I n Pelton, If. J., and 1Jisan, J. V. , eds. Dentistry i n public health. Philadelphia, Sauoders, 1949. XI-363 p.)

6. Kroschel, W, P, Personal communication, A x . 5 , 1953,

7. Moen, B. D, Chicago, American Dental Association, 1955.

Facts about s t a t e s f o r the dent is t seeking a location. 35 p.

8. Mom, B. D. Personal communication, Oct. 20, 1955.

9. Moore, G. B. The orthodontic program of the Michigan State Health Dspart- ment with a new c lass i f ica t ion of occlusion for survey purposes. Ortho., 3k35.5-61, Apr, 1948.

Am. J.

10, Schour, Isaac, and Masslsr, Maury. Gingival disease in postwar I t a l y (1945): I. Prevalence of ginglritia i n various age groupc. Am. Dent. A. J., 35~475-82, Oct. 1, 1947.

11. United State8 Public Health Service, Report o f local public health resourcw, 1952. Washington, Gommmont Pr in t ing Office, 1954, Z-85~.

12, United S ta tes Publ ic Health Service, f ive-year period, 1946-1959. 1952, V - 1 3 1 ~ .

Report o f s t a t e heal th programs f o r Washington, Government Printing Off i c o ,

13. Wallo, R. M., L e w i s , S. R., and Dol la r , &I. L. A study o f the dental needs o f adults in the United States. Am. Dent. A. J., 38:1541-9, Sept, 1941,

14. Warren, R. L, Studying your comxnity, Hartford, Case, Lochrood, and Brainard, 1955. XII-385p. (pa 307)