Center for Native Oral Health Research Research Component 2

Preventing Caries in Preschoolers:

Testing a Unique Service Delivery Model In American Indian Head Start Programs

Study TeamPI: David Quissell, PhD

Terry Batliner, DDS, MBA, Judith Albino, PhD Valerie Orlando, RDH, MEd & Diana Cudeii, RDH

Objectives of Presentation

• Background– Pilot study– Rationale for current project design

• Overview of the Intervention

• Research Design

• Challenges & Opportunities

Background: Pilot StudyCommunity Oral Health Specialist Addresses Early Childhood Caries: A Pilot Study in a Rural Native

American Community

David Quissell, PhD

Nancy M. Reifel, DDS, MPH*

School of Dentistry, UCHSC, Denver, CO

*UCLA School of Dentistry, Los Angeles, CA Sponsor: HRSA Office of Rural Health Policy

Goals & Objectives

1. Local tribal members could be recruited and trained to implement an oral disease prevention program focusing on ECC – Community Oral Health Specialist (COHS

2. Demonstrate the potential for the development of a unique comprehensive community-based Oral Health Promotion Program that would be effective in rural Native American populations

COHS Training Program: Curriculum

• General– Medical emergencies– Caries process– Dental anatomy & nomenclature– Nutrition– Behavioral change

• Procedures– Screening and referral– Caries risk assessment– Oral hygiene instruction– Diet education– Topical fluoride application –varnish– Infection control

COHS Curriculum

• Records– Confidentiality – HIPAA– Knowledge, behavior & outcomes– Submitting clinical encounters– Quality monitoring

Summary of Program Results

• 27 COHS initiated training process; 20 successfully completed training and provided dental health promotion and care over 20 month period

• Across the 2 Tribes, 2,482 children ages 0-4 participated in the program during the 20-month period of operation

Age (at baseline) for Analytic Sample for Intervention

Age # in Sample

<1 year 27

1 year old 34

2 years old 37

3 years old 26

4 years old 40

5 years old 11

2002 Baseline v. IHS 1999 Survey

Data of Dental Clinic Patients 2-5 years of age

Baseline (N=115) IHS (N=498)

Mean S.E. Mean S.E.

dmft 4.59 0.49 5.44 0.24

dmfs 10.33 1.54 13.45 0.84

% of Caries-Free Children by Age(20 months of intervention)

0%

10%

20%

30%

40%

50%

60%

70%

Age 2 Age 3 Age 4

Initial Exam

20 Month Exam

% Children with Untreated Decay(20 months of intervention)

0%

10%

20%

30%40%

50%

60%

70%

80%

Age 2 Age 3 Age 4

Initial Exam

20 Month Exam

Summary of Clinic Outcome Measures:

Following 20 months of intervention

• Doubled number of children without dental decay• Decrease by 50% the number of children

with untreated disease

CNOHR RC 2: Head Start Centers

Southwestern Tribe

Overriding research question

Can a unique service delivery system be developed, utilizing the Community Oral Health Specialist (COHS) model, that is both effective and cost efficient in the prevention of ECC in rural Native American communities?

Alternative Venue for Access to Care: Head Start Program

1. Comprehensive child development program serving children ages 3-5

2. Community-based, child-focused programs 3. Tradition of delivering comprehensive and

high-quality services to foster healthy development in low-income children

4. Performance standards that mandate quality of services -- with oral health among the core health objectives

5. Establish infrastructure for providing the COHS intervention location that has the potential to optimize both the cost efficiency and effectiveness of the intervention

Aims of study1. Develop with tribal and head start center input,

a manualized intervention protocol for ECC prevention program to be delivered by COHS

2. To implement the delivery of FV and OHP programs in AI Head Start Centers under (a) varnish available & (b) COHS OHP program

3. Evaluate the effectiveness of the intervention using both clinical and behavioral outcome measures

4. Cost analysis of the intervention

Protocol Summary• Population – Children 3-5 yrs in Head Start• Study Duration – 5 years including 1 yr for planning,

6 months for recruitment, 3 yrs for implementation, intervention & follow-up exams and 6 months for close-out & data analysis

• Duration of Participation: 3 yrs(a) varnish available vs. (b) COHS OHP program

• Intervention: Application of FV quarterly for 2 yrs and OHP

• Annual evaluation using both clinical (2 yrs) and behavioral outcome measures (3 yrs)

Study Design

• Cluster randomized design – HSC will be matched by population size and randomized within matched strata to the two groups

• All children within HSCs will be invited to participate with informed consent of parents

• Baseline and annual measures of dmfs and questionnaires of dental knowledge, attitudes, and behavior will be completed by parents/caregivers

• Approximately 1,000 children to be enrolled

Inclusion Criteria

Two Intervention Groups:1. Ages 3-5 enrolled in the Tribal HS2. American Indian, as defined by tribe, &

other children at HSC3. Parent/caregiver able to read,

understand and sign a consent form and willing and able to follow study procedures and instructions

Exclusion Criteria

1. If informed consent is not given by parent/caretaker

2. Medical condition or allergy that precludes FV

1. Child experiences adverse reactions

2. If informed consent is withdrawn by the parent/caregiver

3. If they move from the area

Withdrawal from study

Challenges

• Creating community-based partnerships including the tribes, Indian Health Service, Head Start, University and NIDCR/NIH

• Management of a complex project in remote rural areas using multiple performance sites

• Collection and management of significant data base under remote conditions

• Maintain contact with participants for the full three years of their involvement in the project.

• Expect the unexpected!!!!!

Why is this important?

• Over 1000 children will receive annual dental exams and treatment in one of the most remote areas of US

• Head Start families will receive important oral health information and education

• New care delivery model has the potential to improve the oral health status and to reduce the level and severity of ECC in rural Native American communities

• Potential career development & economic opportunities for tribal members as COHS, who can work within their own communities

Questions?

Thank You !!