University-based initiatives towards better access to oral health care for rural and remote populations: A scoping review

This scoping review maps a wide array of literature to identify academic programs that have been developed to enhance oral health care for rural and remote populations and to provide an overview of their outcomes. Arksey and O’Malley’s 5-stage scoping review framework has steered this review. We conducted a literature search with defined eligibility criteria through electronic databases, websites of academic records, professional and rural oral health care organizations as well as grey literature spanning the time interval from the late 1960s to May 2017. The charted data was classified, analyzed and reported using a thematic approach. A total of 72 citations (67 publications and seven websites) were selected for the final review. The review identified 62 universities with program initiatives towards improving access to oral health care in rural and remote communities. These initiatives were classified into three categories: training and education of dental and allied health students and professionals, education and training of rural and remote community members and oral health care services. The programs were successful in terms of dental students’ positive perception about rural practice and their enhanced competencies, students’ increased adoption of rural practices, non-dental health care providers’ improved oral health knowledge and self-efficacy, rural oral health and oral health services’ improvement, as well as cost-effectiveness compared to other strategies. The results of our review suggest that these innovative programs were effective in improving access to oral health care in rural and remote regions and may serve as models for other academic institutions that have not yet implemented such programs.


Introduction
Dental workforce shortages in rural and remote areas have been reported throughout the world [1][2][3][4][5][6][7][8]. Educational and socio-economic background, altruistic motivation, previous life experience, and exposure to rural and remote community activities have been shown to a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 influence dental professionals' decisions in their choice of practice location and willingness to work in a rural and remote area [9][10][11]. Shortages of dental professionals can lead to reduced accessibility to oral health services and poorer oral health status for rural dwellers than for urban populations [2,7,[12][13][14][15]. It has been reported that people living in rural and remote areas have more unmet dental care needs, poorer oral health knowledge and practices and higher rates of dental caries [14,16,17].
The World Health Organization has proposed three strategies to improve access to health workers in rural and remote areas: education and regulatory interventions, monetary compensation and management, environment and social support [18]. A variety of strategies have been recommended to resolve disparities in access to oral health services: prevention and promotion through public health approaches, such as water fluoridation and school-based interventions; facilitating infrastructure and technologies through E-health; temporary services through fly in-fly out or mobile clinic services; financial incentives for the dental workforce in the form of scholarships; interdisciplinary approaches to integration of oral health within primary health care; and academic strategies such as rural training and selective recruitment [7,16,19,20]. Educational institutions have developed strategies to overcome problems due to dental workforce shortages, such as the provision of rural training and outreach programs for dental students, oral health training for allied healthcare professionals and students and selective admission of rural applicants [7,16]. The impact of academic initiatives on an increased rural dental workforce and the concomitant promotion of rural oral health status is less clear, thus emphasizing the need to conduct this comprehensive review.
Over the past decades, various knowledge synthesis methods, such as narrative, integrative, realist, scoping and systematic reviews have been introduced to foster evidence-informed health care [21]. In 2001, Mays, Roberts, and Popay stated that the objective of a scoping review is to rapidly map the fundamental concepts, primary sources and types of evidence on a topic that has not yet been comprehensively reviewed [22]. We mapped a large body of literature to identify rural and remote academic programs and to give an overview of their outcomes, regardless of the quality of the included studies [22].

Materials and methods
The Arksey and O'Malley's scoping review 5-stage framework has steered this review [23]. Accordingly, the scoping review included five steps, as detailed below:

Identifying the research question
One specific research question guided the selection of relevant literature for this scoping review: What are the academic programs and their outcomes that have been designed to enhance oral health care for rural and remote populations?

Identifying relevant studies and eligibility criteria
Pertinent publications that spanned the time interval between the late 1960s and June 2017 were reviewed. The authors searched for publications by using Ovid (MEDLINE and Embase) and PubMed electronic databases. The search strategy (Table 1), designed for the MEDLINE database search, was later adapted for other databases. The electronic search was completed by hand searching the list of references in the identified publications or relevant reviews. Data were also retrieved from the websites of pertinent universities, as well as relevant professional, rural and remote oral health organizations. We included publications written in English only, in which academic institution initiatives on rural oral health care were the focus of the publications. After title and abstract screening, articles were excluded which showed no focus on university-based initiatives on rural oral health. Some of the articles were also excluded after full-text review (30) which were focused on rural oral health initiatives but lacked any interventions. Although editorials, commentaries, and reviews were excluded, their references to the original studies were searched and included in our study.

Study selection
Two independent reviewers (RS, EE) screened the titles and abstracts of each citation and identified eligible articles for full review. Disagreements were discussed and resolved by consensus.

Charting the data
One reviewer (RS) charted all data obtained from the selected publications based on authors, years, country, type of publication, program description, program outcomes measures, and results. The other reviewer (EE) then randomly checked 10% of the extracted data to ensure accuracy. Any noted discrepancy was rectified by consensus.

Collating, summarizing, and reporting the results
The charted data were summarized and reported using descriptive a numerical summary and qualitative thematic analysis approach. Investigator triangulation was conducted by the scoping review team (RS, EE, FP, FT, JF) who reviewed the charts, results and outcome measures.

Characteristics of the included publications
Electronic and hand searches generated 1,487 records (Fig 1). After removal of duplicates, the title and abstract screening was conducted for 1,219 citations, out of which 95 articles were selected for full-text review. From these articles, 65 publications met the eligibility criteria for the scoping review. Additional information was found from 7 healthcare or educational organizations' web records that were relevant to our scope of review. The inclusion of these records then generated a total of 72 records for final synthesis. The scoping review identified a total of sixty-two universities taking initiatives towards improving access to oral health care in rural and remote communities. These publications were identified from 16 countries: USA, Canada, Australia, New Zealand, United Kingdom, Scotland, Malta, Brazil, Peru, India, China, South Africa, Nigeria, Uganda, Romania, and Bulgaria. Most of the included publications were from North America, Asia, and Australia and were published in the last decade.

Program classification
Based on our scoping review results, we identified three categories of programs that have been implemented in various universities. The first category characterizes programs for the training and education of dental and allied health students and professionals [1,3,11,; the second category describes programs for the education and training of rural and remote community members [68][69][70][71][72][73] and the third category represents programs on oral healthcare services in rural and remote areas [41, 42, 61-63, 68, 69, 73-92].

Themes identified in these university-based rural oral health initiatives
All included programs were clustered into the following four themes identified as implementation platforms. These were the curriculum-based platform; joint programs with the public health sector, organizations and community platform, E-health platform, and mobile dentistry   Table 2). Some of the identified programs overlapped under these platforms due to their common objectives.
2. Joint programs with the public health sector, organizations and community platform: This platform for the first category of training and education programs for dental and allied healthcare professionals and students included training of health workers [63]. Aboriginal health workers were responsible for managing patient appointments and communications, as well as oral health promotion activities with the dentists [63]. For its second category of classification, this platform incorporated training of school teachers and the oral health education of children [72]. Finally, for the third category, this platform included programs for oral health promotion: school-based oral health education and services and culturallysensitive oral health care programs with community-led recruitment of its dentist, dental assistant, and Aboriginal health worker [63,[80][81][82][83].
3. E-health platform: This platform offered teledentistry that facilitated the training of an allied dental workforce for the first category of classification [64]. No relevant article was found in relation to the second category of the classification. This platform for the third category of classification included programs focused on oral health services through video consultation with dental specialists and a virtual dental home concept (telehealth dental home) for risk assessment, preventive and operative services and follow-ups [84,85].
4. Mobile dentistry platform: This platform offered programs for the training of students in dentistry and allied dental professions by providing them with experience in mobile dental outreach under the first category [65][66][67]. It included programs focused on patient education for the second category [73]. Finally, for the third category, it encompassed programs that provided oral examinations and consultation, as well as preventive, curative and referral oral health services that improved patients' oral health status [91,92].
Outcome variables.

Outcome variables for oral health service related programs
These outcome variables included community acceptance [82], identification of challenges [63], knowledge, attitude and satisfaction among patients [72,73,75,76], changes in oral health practices [80], changes in oral health status [

Program evaluation results (Tables 3-6)
Outcomes of rural oral health initiatives and their impact varied among these programs. Accordingly, most of the training and education programs were shown to be feasible through feedback from staff, academic personnel, and trainees. For example, these programs were reported to have helped improve students' and trainees' clinical competencies and social sensitization, and provided them with positive experiences and satisfaction [1, 3, 11,  Furthermore, oral health service-related programs had identified and reported community acceptance [82], improved knowledge, attitude and satisfaction among patients [72,73,75,76], improved oral health practices [80], better oral health status [41,42,61,62,70,72,74,86], improved quality of oral health services [48,77,87,88] and enhanced utilization of services [63,68,71,74,78]. These oral health care services included the provision of more interventional procedures compared to preventive and improved referral services. A few programs reported barriers to these outcomes, such as short duration, deeming them insufficient to experience and practice rural dentistry [3]. University-based initiatives towards better access to oral health care in rural areas

Discussion
In most of the countries, rural-urban health disparities are seen not only in dentistry but also in other health disciplines namely medicine, pharmacy, nursing. It is mostly linked to the disproportionate distribution of health care providers including dentists, physicians, nurses, and pharmacists [8,93]. Government organizations, for-profit and non-profit non-governmental organizations and academic institutions around the world have taken several steps towards improving access to rural dental care. In this extensive literature scoping review, we have reported evidence of academic institutes' initiatives in improving access to oral health care for rural and remote communities. Outcomes of this scoping review revealed that students benefitted from these university initiatives by having opportunities to work in real-world situations that inspired them to learn [46], practice various procedures, manage the diversity of patients and gain experience working in a team [26]. Indicators for the success of these programs were: students' satisfaction with the program, community-based experience, enhanced communication skills and selfconfidence; a high rate of treated patients; reduced oral health problems in rural areas after rural placements; and an increased percentage of students working in rural dental practices [1, 3, 11, 24-27, 29, 31, 33-43, 47, 49-52, 54-65, 67, 68, 70-72, 74, 78, 84, 86]. The effectiveness of rural exposure through training in universities and institutions was found to vary due to reasons such as the short duration of rural placement programs, as well as a lack of standardized methodologic and evaluation tools [94]. According to Lalloo et al., confidence among dental students in choosing a dental practice in rural areas was the most relevant outcome measure of the impact of students' rural placement programs [31]. Orpin et al. commented that the subsequent fair distribution of the rural workforce would be the ultimate test in evaluating the effectiveness of these kinds of programs, although that would be a long-term vision [94]. Rural areas, by virtue of being smaller, offer better opportunities for any program to be successful due to logistical ease of administrative coordination and collaboration, with less organizational and managerial impediments than in urban settings [16].
Most of the mobile dental clinics, dental camps, and dental outreach programs successfully disseminated awareness, provided treatment and enhanced access to care for people living in rural areas. Results from the various outreach programs showed that they could assist in bridging the wide gap created between rural residents' actual dental needs and their demand for dental care [71,73,[75][76][77][78]87]. Integration of telehealth into rural oral health services is likely University-based initiatives towards better access to oral health care in rural areas University-based initiatives towards better access to oral health care in rural areas  to be successful, but more time is needed to realize the full oral health implications of rural Ehealth technology [16].
In most of the programs, universities received funding from various sources, but some programs could not be continued due to lack of funding [63,68]. If the necessary funds become available, it is expected that these services could be provided at a marginal cost when compared to the costs of similar treatments provided by either public-sector staff or private practitioners [79]. The strong motivation of academia's initiatives to improve oral health care access for rural and remote communities appears to be justified by their positive and effective results; however, long-term evaluations by the institutes and their partners are crucially needed. Most often, curative services were provided in these programs; hence, there is a need to shift our focus towards preventive and promotional oral health services to achieve the global vision of eliminating oral health disparities among rural and remote communities. Training undergraduate dental students has the potential to improve dental services in rural areas, particularly in areas with limited or no publically-funded dental services [79]. The total cost of the services provided by students, including their travel, living and supervision, is lower than that of private dental providers [79]. The results of our scoping review suggested that very few outreach programs were found to be cost-effective [41,81,92]. These programs not only significantly reduced the cost of setting up dental clinics or mobile dental clinics but also further lower costs by using available local resources and staff, such as school teachers [81]. However, long term evaluation are required to determine true cost-effectiveness of these programs. One study demonstrated the cost-effectiveness of a rural outreach program using a portable dental unit [92]. The cost of dental services provided by students with mobile dental units may be high initially, but they become cost-effective over time. [41].
The types of academic initiative programs stated in our scoping review benefited both the rural communities and the academic institutions. Rural residents gained access to dental services and students from the academic institutions gained experience in their field and had an opportunity to develop clinical practice skills by providing care to a broad range of patients.
The WHO has provided strategies and recommendations on improving access to health workers in rural and remote areas [18]. According to these strategies, medical and dental schools were identified as playing a major role by enrolling students from rural backgrounds , results from our scoping review reveal the major contribution of such institutions through student rural rotations and by enrolling students from rural areas for health promotion activities, thereby reducing cost and related expenditures. However, some countries like Australia has established new dental schools predominantly in rural and remote areas with the aim of increasing the recruitment of rural students, and ultimately providing a rural workforce. Our scoping review identified the following gaps in the existing literature on academic initiatives in rural and remote areas. These include great variability in program design, duration, data collection tools (often non-standardized), more focus on curative dental services as opposed to preventive or promotive services and lack of sustainable financial support.

Limitations
The main limitations of this scoping review are twofold. Firstly, the literature review was restricted to articles written in English only. There is likely published work in some other areas of the world like Europe and South America in other languages. Secondly, these publications were not assessed specifically for scientific quality; thus, the results of this scoping review should be interpreted carefully.

Recommendations
These findings point to the following empowering 'next steps' for international universities and training institutes: development of international partners to conduct long-term program evaluations; create a mandate to expand and sustain rural residency programs; build strong partnerships with public and private health sectors; promote interdisciplinarity of rural health provision; and build links with policy makers to mobilise the support, development and implementation of universal academic rural and remote oral health programs. Future programs could be customized to address the disparities for a country's or region's rural health care needs while considering the administrative, educational and fiscal structure of dental faculties and their universities.

Conclusion
This scoping review describes university-based initiatives in improving access to oral health care in rural and remote regions. The results suggest that these innovative programs are transferable and may serve as valuable models for other academic institutions to promote the oral health of rural and remote populations and improve their right of access to oral health care.