Building oral health assignments for community health workers through the Delphi technique

Sass, Alex Luís; Hugo, Fernando Neves; Silva, Aline Hübner da; Corralo, Daniela Jorge; Trentin, Micheline Sandini

doi:10.1590/1413-81232021263.04232019

Alex Luís Sass

Clínica Odontológica, Faculdade de Odontologia, Universidade de Passo Fundo. Av. Brasil Leste 285, São José. 99052-900 Passo Fundo RS Brasil. alexsass@gmail.com

https://orcid.org/0000-0001-9202-5392

Fernando Neves Hugo

Faculdade de Odontologia, Universidade Federal do Rio Grande do Sul. Porto Alegre RS Brasil.

https://orcid.org/ 0000-0003-2222-7719

Aline Hübner da Silva

Clínica Odontológica, Faculdade de Odontologia, Universidade de Passo Fundo. Av. Brasil Leste 285, São José. 99052-900 Passo Fundo RS Brasil. alexsass@gmail.com

https://orcid.org/ 0000-0002-6327-6018

Daniela Jorge Corralo

Clínica Odontológica, Faculdade de Odontologia, Universidade de Passo Fundo. Av. Brasil Leste 285, São José. 99052-900 Passo Fundo RS Brasil. alexsass@gmail.com

https://orcid.org/ 0000-0003-3034-1730

Micheline Sandini Trentin

Periodontia, Faculdade de Odontologia, Universidade de Passo Fundo. Passo Fundo RS Brasil.

https://orcid.org/ 0000-0001-5040-3578

Collaborations

AL Sass: developed the research, analyzed the results, and wrote the article. FN Hugo: helped to advise the research and analyze the results. MS Trentin: advised the research and the writing of the article. AH Silva: revised the scientific article. DJ Corralo: helped to write and revise the scientific article.

Chief editors: Romeu Gomes, Antônio Augusto Moura da Silva

Registration of Families
1	When registering the families, CHW should access information that helps to identify the groups of oral health promotion, protection, and recovery actions.
2	The CHW may contribute to identifying the groups of oral health actions by using indicators of oral health diseases.
3	The CHW should identify simultaneous risk or protection factors for diseases of the oral cavity and other diseases (diabetes, hypertension, obesity, cancer, and people with disabilities).
4	The CHW should identify the main risk factors, such as lack of access to oral hygiene products, excessive and frequent sugar intake, and frequency of dental visits of the families.
5	Mouth cancer is among the main causes of death by neoplasia. Its prevention is simple by focusing on health promotion, increased access to health services, and early diagnosis. The CHW should identify risk situations for mouth cancer in families, such as smoking, alcoholism, and exposure to solar radiation.
6	Programed health care is characterized by people registered in the area who are included in the priority group of the health care unit and require continuing care. It is up to CHW, along with the OHT and the community, to identify these groups.
7	It is up to CHW to identify people with special needs who need to be classified as a priority dental care group.
8	The oral health risk groups identified by CHW are based on criteria of frequency, risk, and vulnerability to diseases, according to the needs of the local population.
Mapping the Coverage Area
9	Mapping the coverage area of CHW should contribute to diagnose and plan OHT actions. It should also provide relevant oral health information, including access to piped water, private dental offices, and infrastructure of services available.
10	The oral health mapping should identify information in the registration of families regarding oral health risk groups and situations.
11	This map should also identify priority dental care groups.
12	The OHT should cooperate with CHW to formulate this oral health mapping.
13	The mapping should allow the OHT and CHW to assess interdisciplinary risk situations that relate oral health to other health problems.
Home Visits
14	During home visits, CHW should comply with the plan developed along with the OHT, based on the needs of every family. New risk situations or groups may be identified during the visit, requiring a new plan.
15	During home visits, CHW should stimulate self-care practices in patients for oral health prevention and promotion.
16	During home visits, CHW should identify situations that require diagnosis, treatment, and rehabilitation measures and refer them to the OHT.
17	The oral health home visits should be planned along with the OHT.
18	The CHW may perform educational and preventive procedures in the households, according to the plan established along with the OHT.
19	The CHW should prioritize home visits to oral health risk groups and situations, according to the diagnosis and planning established along with the OHT.
Work with Community Health Education
20	The content that CHW may address in educational actions includes oral diseases, diagnosis, and prevention; self-care, oral hygiene, toothbrushing with fluoridated dentifrices, and use of dental floss; instructions about diet, oral self-examination, and care after dental trauma; and consumption of alcohol, tobacco, and drugs.
21	The actions of CHW in educational activities should be planned along with the OHT, defining actions per cycle, living conditions, and common risk factors to several diseases.
22	The oral health educational activities performed by CHW should comply with the methodologies and didactics defined along with the OHT.
23	It is up to CHW, during health educational activities, to explain the functioning of oral health care provided by the city, including information about making appointments, procedures performed, the modality of health care, and secondary and tertiary health care flow.
24	The CHW should support and develop oral health activities with the other members of the Family Health Team, integrating health actions in an interdisciplinary manner.
25	The oral health educational activities performed by CHW should not overlap the activities performed by the OHT and they should have a complementary character of oral health surveillance and promotion, as defined in the action plan.
Participation in the Community
26	It is up to CHW to exchange knowledge with the community of their micro-area, helping the OHT to develop strategies to face the existing problems.
27	The knowledge exchange by CHW with the community may help the OHT to identify the challenges faced by the population regarding access to oral health care in BHU.
28	The CHW should identify social spaces in their micro-area, contributing to the oral health planning of the health team.
29	The CHW should verify oral health challenges in the community and strategies suggested for facing the problems.
30	During the work process, CHW should know, in the community, the living conditions, habits, and measures to solve problem situations and prevent oral health diseases.
Intersectoral Work
31	It is up to CHW to identify sectors and players outside the health field who may contribute to the planning of oral health actions.
32	The identification of these sectors by CHW should be based on criteria of risk, work potential, and resources available for oral health work.
33	The CHW should recognize conditionalities that interfere with the oral health of individuals such as participation in government social programs (e.g., Bolsa Família) or any other similar income transfer program.
34	The CHW, along with the OHT, should participate in the planning of actions of the School Health Program, helping to identify criteria of risk, resources available, and performance of collective procedures.

Dimensions of the work process of CHW	First phase	Second phase
Registration of families	No suggestions.	There were no comments on this dimension.
Mapping the coverage area	1- Location of social spaces (schools, daycares, religious groups, residents' associations) to potentiate actions or identify risk sites. 2- To specify the families with individuals who are bedridden/unable to go to the BHU.	1- Sites of difficult access should be identified, such as hills or slopes and/or sites of urban violence; areas with quilombola and camped communities, riparian people, and/or others included in the modality of Family Health team 1. 2- The fact that they are bedridden or have special needs does not make them a priority. They should be identified so the service finds them.
Home visits	3- Inclusion of a topic about bonding during the home visit of CHW, according to OHT assignments.	There were no comments on this dimension.
Work with community health education	4- The activities should meet the habits and culture of the population registered. 5- The CHW has a prescriptive/normative educational posture limited to what is "right or wrong" for users, without considering the context of replication of booklets and manuals from the Ministry.	3- It is important to consider the knowledge and experience of participants, allowing the exchange of ideas. This stimulates people to build a decision-making process that is autonomous and centered on their interests. 4- It is concerning to deal with several skills for the work of CHW and completely disregard the FHS. It seems that there will be separate schedules for health and oral health tasks. 5- The conversation of habits and culture should not be an exclusive assignment of CHW, but the entire team.
Participation in the community	6- Identification and creation of the therapeutic plan considering the Integrative and Complementary Practices of the Brazilian Public Health System¹⁸18 Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2017..	- Questions 8 and 9 are not aligned with the premise of participation in the community, as they would relate better to the assignment of health care practices. Therefore, they are considered irrelevant to this component.
Intersectoral work	- Exclusion of items 31 and 32 for not reaching the mean and standard deviation. - It is "also" up to CHW, in item 31, to identify sectors and players outside the health field who may contribute to the planning of oral health actions. - Topic 32 depends on the previous knowledge of risk factors and their interpretation, which would be a little far from the reality of CHW, as mentioned in the observations of the first entry field regarding the registration of families. - Items 31 and 32 should be performed by the FHS team.	- There were no comments on this dimension.

Registration of Families
1	Identification of groups of oral health promotion, protection, and recovery actions.
2	Identification of simultaneous risk or protection factors for diseases of the oral cavity and other diseases (diabetes, hypertension, obesity, cancer, and people with disabilities).
3	Identification of the main risk factors, such as lack of access to oral hygiene products, excessive and frequent sugar intake, and frequency of dental visits of the families.
4	Identification of risk situations for mouth cancer in families, such as smoking, alcoholism, and exposure to solar radiation.
5	Identification of people with special needs classified as priority dental care.
6	The risk groups identified by CHW are based on criteria of frequency, risk, and vulnerability to diseases, according to the needs of the local population identified in diagnoses performed by the OHT.
Mapping the Coverage Area
7	To provide relevant oral health information, including access to piped water, private dental offices, and infrastructure of services available that may affect oral health.
8	Information should be identified in the registration of families regarding oral health risk groups and situations.
9	To identify priority dental care groups, according to the data obtained in the registrations.
10	The OHT should cooperate with CHW to formulate this oral health mapping.
11	Allow the OHT and CHW to assess interdisciplinary risk situations that relate oral health to other health problems.
12	The CHW should locate or map organized social spaces (schools, daycares, religious groups, residents' associations, etc.) to plan oral health actions along with the OHT.
13	Bedridden individuals unable to go to the BHU and special needs patients should be classified as priority dental care groups.
Home Visits
14	To comply with the plan developed along with the OHT, based on the needs of every family. New risk situations, people, and families may be identified during the visit, requiring a new plan.
15	To stimulate self-care practices for oral health prevention and promotion.
16	To identify situations of diagnosis, treatment, and rehabilitation and refer them to the OHT.
17	To include collective, educational, and preventive procedures that may be performed in the households by CHW, according to the plan established along with the OHT.
18	To prioritize home visits to oral health risk groups and situations, according to the diagnosis and planning established along with the OHT.
19	To induce mild technologies, creating welcoming and health care processes in oral health aiming to identify the needs of users and the best way to meet them.
Work with Community Health Education
20	The content that CHW may address in educational actions should include oral diseases, their manifestation, and prevention; the importance of oral hygiene self-care, toothbrushing with fluoridated dentifrices, and use of dental floss; prevention of fluorosis; instructions about diet, oral self-examination, and care after dental trauma; prevention of unprotected solar exposure; and consumption of alcohol, tobacco, and drugs.
21	The actions should be planned along with the OHT, defining actions per cycle, living conditions, and common risk factors to several diseases.
22	The actions should comply with the methodology and didactics defined along with the OHT.
23	The actions should support and develop oral health activities with the other members of the FHS, seeking to approach and integrate health actions in an interdisciplinary manner.
24	The actions should not overlap the activities performed by the OHT and they should have a complementary character of oral health surveillance and promotion, as defined in the action plan.
25	The oral health education performed by CHW should meet the habits and culture of the population registered.
26	The CHW should know, in the community, the living conditions, habits, and measures to solve problems and prevent oral health diseases.
Participation in the Community
27	It is up to CHW to exchange knowledge with the community of their micro-area, helping the OHT to develop strategies to face the existing problems.
28	The knowledge exchange by CHW with the community may help the OHT to identify the challenges faced by the population regarding access to oral health care in BHU.
29	The CHW should identify social spaces in their micro-area, contributing to the oral health planning of the health team.
30	The CHW should verify oral health challenges in the community and strategies suggested for facing the problems.
Intersectoral Work
31	The CHW should recognize conditionalities that interfere with the oral health of individuals such as the participation in government social programs (e.g., Bolsa Família) or any other similar income transfer and vulnerability coping programs implemented by the Brazilian Federal, state, or city governments.
32	The CHW, along with the OHT, should participate in the planning of FHS actions, helping to identify criteria of risk, resources available, and performance of collective procedures.

Dimension	Weighting of criteria in the dimension (weight/total score)	Value assigned (weighting x100)
Registration of families	0.004 0.009 0.014	0.40 0.90 1.4
Mapping the coverage area	- 0.007 0.011	- 0.7 1.1
Home visits	0.004 0.008 0.012	0.4 0.8 1.2
Work with community health education	0.003 0.006 0.010	0.3 0.6 1.0
Participation in the community	- 0.011 0.016	- 1.1 1.6
Intersectoral work	- 0.020 0.040

[1] Collaborations

AL Sass: developed the research, analyzed the results, and wrote the article. FN Hugo: helped to advise the research and analyze the results. MS Trentin: advised the research and the writing of the article. AH Silva: revised the scientific article. DJ Corralo: helped to write and revise the scientific article.

Brasil

Brasil

Building oral health assignments for community health workers through the Delphi technique

Abstract