Sustainable oral health interventions.

How can we best implement evidence-based health promoting interventions that are sustainable, scalable and are either self-supporting (e.g. reimbursable services) or require few continuing resources? Simpson (1) provides an excellent multi-stage model based on four stages: training, adoption, implementation and practice improvement. His model is most applicable to private practice settings with office-based institutional resources and emphasis on staff needs, attributes, and acceptance. Simpson's model does not specifically include a public health perspective. The intervention's public health characteristics should be considered as should larger system-level factors in which public health programs operate. Meeting consumer needs and active community engagement are also critical. As described in Jong's text (2), “an ideal public health measure [intervention] should be: (1) of proven efficacy in the reduction of the targeted disease; (2) medically and dentally safe; (3) easily and efficiently implemented, utilizing a relatively small amount of materials, supplies, and equipment; (4) readily administered by nondental personnel; (5) attainable by the beneficiaries regardless of their socioeconomic, educational, income and occupational status; (6) readily available and accessible to large numbers of individuals; (7) inexpensive, therefore affordable by the majority; (8) uncomplicated and easily learned by the utilizers; (9) administered with maximum acceptance on the part of the patient(s); and (10) administered with minimum compliance on the part of the patient(s).” Conditions in the larger system or environment can help promote, enable and sustain programs. These include legislation, clinical practice guidelines, health policies, collaborative, inter-professional and inter-sectoral approaches (e.g. working with school systems) incorporating oral health with other health or educational activities, and, working with the media to add positive oral health messages and images in news and entertainment formats. For program continuation, good data are needed for quality improvement and monitoring to determine if objectives are being met and adhere to the organizational mission. Identifying and meeting customer needs, as discerned by professionals and the targeted groups, building community partnerships, and environmental responsibility are increasingly important. For consumer acceptance, where and when the intervention is delivered makes a difference, whether it is at home, school, workplace or other group setting (e.g. CenteringPregnancy® group model for delivering oral health messages to pregnant women.) A local champion is perhaps essential for program initiation, but to be sustainable a program must be able to survive beyond individual leaders and particular political administrations. Oral diseases are multifactorial. Individuals and systems interact in different ways over the life course, with priorities changing over time (3). Multiple interventions that complement and reinforce each other, and involve a range of community partners and stakeholders may be more effective than single interventions. Future sustainable health interventions will make use of new technologies, electronic health records, mobile smart devices, shared information platforms, and social media to assist with marketing, dissemination, implementation, program refinement and outcome monitoring. Tailored, community demand-driven approaches with local champions will be adopted. Those programs that meet customer needs, build trust, are evidence-based, efficient, accountable and supported by oral health professionals and larger organizational systems are likely to be sustained.