Dental education in the rural community: A Nigerian experience

Abstract

At the University of Ibadan, Ibadan, Nigeria, dental students are prepared not only to provide skilled care to individual patients, but also to assume responsibility for the community as a whole. In establishing the rural posting program for dental students, it was planned that all fifth year dental students would undertake a rural posting at Igboora, approximately 80 km from Ibadan, the capital of Oyo State. During this 6 week immersion experience students learn about living in a rural area where they provide community oral health services. This report provides recommendations for initiating, sustaining and expanding rural dental education programs.

Full text

© O Ibiyemi, JO Taiwo, GA Oke, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au 1
P R O J E C T R E P O R T
Dental education in the rural community: a Nigerian
experience
O Ibiyemi, JO Taiwo, GA Oke
Department of Periodontology and Community Dentistry, Faculty of Dentistry, University of Ibadan,
Ibadan, Nigeria
Submitted: 30 May 2012; Revised: 3 August 2012, Accepted: 4 December 2012 Published: 18 February 2013
Ibiyemi O, Taiwo JO, Oke GA
Dental education in the rural community: a Nigerian experience
Rural and Remote Health 13: 2241. (Online) 2013
Available: http://www.rrh.org.au
A B S T R A C T
At the University of Ibadan, Ibadan, Nigeria, dental students are prepared not only to provide skilled care to individual patients, but
also to assume responsibility for the community as a whole. In establishing the rural posting program for dental students, it was
planned that all fifth year dental students would undertake a rural posting at Igboora, approximately 80 km from Ibadan, the capital
of Oyo State. During this 6 week immersion experience students learn about living in a rural area where they provide community
oral health services. This report provides recommendations for initiating, sustaining and expanding rural dental education programs.
Key words: dental education, Nigeria, rural posting, underserved and underprivileged areas.
Context
Despite worldwide adoption of the UN Alma-Ata declaration
as a strategy for achieving ‘Health For All’, some medical
education systems are still ‘ivory towers’, remote from their
health service system
1
. In African countries, basic medical
education has been largely hospital-based, technologically
oriented and focused on curative therapies at the expense of
preventive and promotive care
2
. This has produced medical
doctors and dentists who are able only to work in secondary
and tertiary health centers, leaving primary healthcare (PHC)
centers underserved or neglected. Further, this traditional
medical education does not prepare doctors in developing
countries for a leadership role in meeting the healthcare
needs of an entire population, particularly those who live in
rural areas
1
.

© O Ibiyemi, JO Taiwo, GA Oke, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au 2
Fortunately some governmental and non-governmental
agencies support the establishment of community-oriented
medical schools where doctors are trained to offer broad-
based community care and preventive medicine
3
. To this end,
many medical schools have established rural- or remote-area
postings for medical students with the aim of addressing
community health needs
3
. Similarly, some dental schools,
such as the Dental School, University of Ibadan Ibadan,
Nigeria, have addressed the need to establish rural dental
education postings for dental students, with the aim of
providing preventive and curative oral health services to rural
underserved and disadvantaged communities. In addition, this
rural undergraduate dental curriculum exposes dental
students to rural practice and lifestyle, and so encourages a
desire to work as graduates in areas of unmet oral health
need.
The clinical dental training program of the Dental School
University of Ibadan, Nigeria is based at the Dental Center
University College Hospital Ibadan, the capital of Oyo State.
Although community dentistry is part of the undergraduate
curriculum, there has been no rural or remote area exposure
for dental students to apply didactic knowledge and skills.
This report provides information about the establishment of a
rural dental posting program from the Dental School
University of Ibadan, Nigeria in 2007. This will assist the
establishment of such a program in other dental schools,
especially those in developing countries. It will also provide
information relevant to the community engagement and rural
oral health programs of local and international governmental
and non-governmental organizations that have an interest in
providing oral health services, especially for people in
underserved locations.
Program
In 2007, the Department of Periodontology and Community
Dentistry, Faculty of Dentistry at the University of Ibadan
established the Ibarapa Community Oral Health Programme
at Igboora (Fig1), a rural community and headquarters of
Ibarapa Central Local Government Area of Oyo State,
Southwestern Nigeria. Igboora is situated approximately
80 km west of Ibadan and has a population of approximately
60 000 whose main occupations are farming and trading
4
.
This rural dental posting program was established to provide
oral health care for the population in and around Ibarapa,
while also providing community based dental education
where students can observe the determinants of ill-health for
those in disadvantaged communities. The program was
funded by the US MacArthur Foundation and is strongly
supported by the Vice Chancellor of the University of Ibadan,
the Provost College of Medicine, and the Director of the
Ibarapa Community Health Programme. A committee
consisting of consultants in community dentistry, resident
doctors in community dentistry, dental officers, a public
health nurse and an administrative officer was assembled to
manage the activities of the Programme. In early meetings the
committee mapped strategies to achieve Programme aims and
objectives. The committee also met with the management of
the Ibarapa Community Health Programme, a collaborative
program between Ibarapa communities, administrators of the
three Ibarapa Local Government Areas (LGAs), the Oyo
State Government, University College Hospital Ibadan and
the University of Ibadan to ensure effective integration of the
oral health program into existing health facilities at the
General Hospital Igboora. Additional discussions, strongly
supported by the Dean Faculty of Dentistry University of
Ibadan, centered on ensuring that dental and medical
students’ rural postings coincided, in order to promote the
sharing of ideas and knowledge about the healthcare needs of
this population.
A familiarization visit to the General Hospital Igboora was
made by both the Ibarapa Community Oral Health and
Community Health teams. During this visit the teams
inspected facilities such as consulting clinics, laboratories,
pharmacy, wards, theatres, lecture rooms, staff
accommodation and recreation areas, and water collection
points.

© O Ibiyemi, JO Taiwo, GA Oke, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au 3
Saki West
Saki East
Orelope Olorunsogo
Orire
Atiba
Itesiwaju
Kajola
Iseyin
Iwajowa
Ogbo
North
Ogbo
South
Ibarapa North
Ido
Ibarapa
Central
Afijo
Oyo West Ogo Oluwa
Oyo east
Akinyele
Lagelu
Egbeda
Ona Ara
Oluyole
1
2
3
4
51 Ibadan North LGA
2 Ibadan North East LGA
3 Ibadan South East LGA
4 Ibadan North West LGA
5 Ibadan South West LGA
Key
Ibarapa
East
BENIN REPUBLIC
KWARA STATE
KWARA STATE
OGUN STATE
OSUN STATE
10 0 10 20 30
Study Area
Atisbo
Surulere
Irepo
Igboora
2 45'E
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0
Figure 1: Map of Ibarapa Central Local Government Area, Oyo State, Nigeria.
Following this visit, two rooms were allocated to the dental
clinic, appropriate accommodation was provided for the
dental surgeons, and female and male dormitories were
allocated to the dental students participating in the Ibarapa
Community Oral Health Programme. It had been noted that
a report on rural practice preferences among medical
students in Ghana showed that the students valued rural job
attributes that enabled them to perform well clinically and
live comfortably
5
. Therefore, the allocated accommodation
facilities were renovated to assist in motivating students. At
the same time dental materials, instruments and equipment
were purchased for the dental clinic, and an Indigenous in-
house trained clinic assistant from the local community was
employed.
The dental clinic was commissioned by the traditional ruler
and chiefs of Igbo-ora in the presence of the administrative
heads of the Ibarapa Central LGA and the Dental School,
University of Ibadan. This was followed by oral healthcare
training for school teachers and community health workers in
Ibarapa Central LGA in order to create awareness of oral
health care, and to develop their capacity to identify and refer
people with oral disease from the community.
Issues
Each year, towards the end of the academic session, 35 to 40
fifth-year dental students who have acquired adequate clinical
training in dentistry and medicine are scheduled for a six-
week rural dental posting. The posting usually coincides with
medical students’ rural medical posting to encourage
interaction between the two groups of students. Prior to
travelling to Igboora, dental students spend the first week of
the posting at the Dental Center, University College Hospital
Ibadan, receiving lectures on research methodology and

© O Ibiyemi, JO Taiwo, GA Oke, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au 4
developing a group research project relevant to the needs of
the community. At this time they are also briefed on the rural
dental education program and collect their posting booklets.
On arrival at Igboora at the beginning of the second week,
students are received by a senior registrar in community
dentistry, and the administrative officer of the Ibarapa
Community Health Programme orients them to their
dormitory accommodation, the taps and tanks for fetching
water for drinking and bathing, and the canteen where they
will purchase food.
On the second day after arrival, a program work schedule is
provided by the senior registrar who then takes the students
on ‘advocacy visits’ to administrative and traditional leaders
in the community, with the aim of establishing trust and good
will. At this time, rural dental education program objectives
are explained to the leaders to encourage community
participation and involvement in matters that fundamentally
affect the delivery of local health services. This is an
important program ethical component
6
, and it is hoped that
support from the community will influence these
undergraduate students’ future willingness to work in rural
communities
7
.
Guided by the work schedule, the dental students then visit
diverse populations at immunization and antenatal clinics,
market places, schools, LGA secretariats and the meeting
place of artisans. There they perform community diagnosis by
screening individuals for oral disease. Those with oral disease
are referred for routine dental treatments at the Dental
Clinic, General Hospital Igboora; and patients requiring
specialist dental care are referred to the Dental Centre,
University College Hospital Ibadan. The students also
provide education about the prevention and treatment of
common oral diseases, especially those prevalent among
disadvantaged socioeconomic groups. To this end, one group
of dental students composed a folk song about oral hygiene
maintenance which is now sung in primary and secondary
schools in and around Ibarapa.
The dental students commence their group research project,
guided by the senior registrar who assists with organizing
surveys and interpreting findings. However, the main
initiative remains with the students. All posting activities are
performed under the supervision of lecturers and consultants
in community dentistry, assisted by dental officers on
rotation in community dentistry. These mentors guide and
motivate the students for the duration of their posting, for
the positive impact of supportive supervision has been found
to improve health workers’ motivation and quality of care
8,9
.
The students’ activities are problem-based, self-directed and
student-focused, which Schmidt et al reported to be more
beneficial than rote learning when students are dealing with
community health problems, because students are highly
motivated to acquire the necessary skills for problem
solving
10
.
However, during scheduled visits to Igboora, dental student
lectures on oral disease epidemiology and biostatistics,
provided by lecturers in community dentistry, complement
the structured community observation and investigation. In
addition, students make group presentations on oral health
issues in rural communities as graded assignments. Both
lectures and presentations are interactive and guide students
in their activities, for it has been reported that medical
students perceive the absence of guidance as negative factor in
community based training
7
. The formal education component
also includes clinical laboratory demonstrations and hands-on
practical experience in basic investigatory procedures, such as
estimating packed cell volume (PCV) and performing full
blood counts. Students also participate in environmental
health and community development programs presented by
health and development officers.
Two days before the end of the posting, students participate
in a ‘research-to-policy program’, where feedback on the
outcome of their research is provided to the representatives
of various population groups, community leaders and
administrative LGA heads, with suggestions for corrective or
preventive healthcare actions. Finally, a cultural night
provided by the Chairman of the Ibarapa Central LGA shows

© O Ibiyemi, JO Taiwo, GA Oke, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au 5
the community’s appreciation for the services of both medical
and dental students.
On the dental students’ return to Ibadan they give oral
presentations of their group research outcomes at the
University of Ibadan and are scored by the heads of the
various departments in the Faculty of Dentistry. The group
research project is also submitted as a thesis and scores are
awarded as part of continuous assessment for the final
Bachelor of Dental Surgery Examination in Community
Dentistry.
Lessons learned
The power of knowledge lies in its application. Rural postings
enable students to translate theoretical knowledge into
practical skill-acquiring experiences and to make a real
difference to the local community. Due to their proximity to
patients, students are able to understand their illnesses; they
come to understand how the community works and are able
to observe the various determinants of oral health. Anecdotal
reports have shown that the majority of dental students who
attended the rural posting found that the rural dental
education experience met their expectations. The program
sensitized them to, and so helped them to identify,
community needs. They reported being able to work as a
team while also developing problem-solving and self-directed
learning skills. They applied their problem-solving skills to
the provision of health care, based on available resources, the
local ecology, and the culture and traditions of the local
population.
This posting also enhances the image and practice of the
dental profession, making dental students highly acceptable to
the people, and dental education relevant to community
needs. This rural, community-oriented and problem-based
educational strategy is an immersion experience that will
better prepare dental students for graduate practice, and
assist in addressing shortages of dentists in cross-cultural and
disadvantaged communities. Importantly, in the long term it
will assist in recruiting and retaining dentists in rural and
remote areas, for exposure to rural health care during
training is one of the predictors of health professionals’ choice
for graduate jobs in rural areas
11-14
. The rural exposure of
dental students will result in dentists with a strong
orientation towards priority oral health problems and
community programs. It will also help students adopt an
holistic approach in their future clinical work. Furthermore,
it will strengthen the performance of newly graduated
dentists posted to PHC facilities in rural communities for
their one year National Youth Service Corps in oral health
services. Urban students who have experienced rural-based
training placements will not have the cultural shock
encountered by those who have had no experience of life in
rural areas
15
.
Kaye et al mentioned inadequate support facilities such as
internet and library access as challenges to rural medical
programs
7
. This was observed to be an issue in this program
and correction has been recommended, for adequate support
facilities will better position rural medical and dental student
on rural postings to meeting their goals. The majority of
final-year medical students at the University of Lagos,
Nigeria, whose rural exposure was in the PHC program of
their school reported that the program should not only be
retained, but also better funded to achieve desired
objectives
16
. Financial support from government will
motivate students to participate, and will ultimately
contribute to the development of a viable rural and remote
workforce.
Finally, while some students found it difficult to understand
the local language and culture, this was managed by dividing
students into mixed groups of those who could speak and
understand local languages and culture and those who could
not. Students able to translate the local language into English
were encouraged to assist their colleagues.
Conclusion
Undergraduate exposure to rural health care has been found
to assist in the recruitment of dentists for rural service, and
their subsequent retention. Dental schools, especially those in
developing countries, should contribute to providing oral

© O Ibiyemi, JO Taiwo, GA Oke, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au 6
health for all by developing a rural dental education program.
The rural dental training program of the Dental School,
University of Ibadan, Nigeria has been a success since its
establishment in 2007, providing a model for those wishing
to establish such a program. However, it is important that
local and international governmental and non-governmental
organizations promote oral health and support the provision
of oral healthcare services in partnership with regional and
national ministries of health, especially for disadvantaged
rural populations.
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