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Making the correct match will also influence where therapists are most efficiently deployed to their “home� villages. A high proportion of broken appointments is an inefficient use of resources. However, as we noted, broken appointments may be indicative of the longstanding behaviors and attitudes of community residents who will be resistant to change. Effecting change within the context of community norms is the most daunting challenge facing dental services and improvements in oral health in rural Alaska.

5.5.3 Community Context The paramount factors in the community context of oral health are diet and adoption of personal oral health practices: brushing and flossing. The 2004 Alaska Traditional Diet Survey was conducted by the Alaska Native Epidemiology Center of the Alaska Native Health Board to document the quantity of subsistence foods consumed by residents of rural Alaska villages. Food frequency questionnaires were administered in five areas of Alaska, four of which include the tribal organizations that participated in the DHAT program evaluation. In all four areas, soda pop or other sugared drinks were the first or second most frequently consumed food item by quantity. Soda pop is ubiquitous in the villages, and frequently we witnessed cases of soda pop occupy most of the cargo space on the small planes that supply these villages. In all of the village sites we visited, soda pop was much more common and less expensive than bottled water. The oral health habits of the villages varied across sites. In Site C, where the percentage of participants with untreated decay ranged from 85% to 100%, the project dental examiner was struck by the number of teenage girls he examined who had extensive anterior interproximal caries (decay between their front teeth). He predicted than many would be edentulous (have no teeth) by their early 20s. Site B was where the smallest proportion of participants had untreated decay (29% to 48%). We can only speculate as to what accounts for these differences, but there appeared to be a greater awareness of the importance of brushing and flossing among the parents in Site B. Socioeconomic factors also likely contribute, as Site B has a more vibrant commercial economy. With nonstop air service to Anchorage, the residents have opportunities to have a more varied diet. In Site B, the therapist is operating a school-based educational program that includes fluoride rinses. In Site C, there is very limited contact between the therapist and the school. The evaluation, however, was not designed to answer these questions. Nonetheless, these are powerful contextual influences that reflect social norms that will take substantial time to change before oral health improves.