Preventing Cavities in Preschoolers: Testing a Unique Service Delivery Model in American Indian Head Start Programs

1. Preventing Cavities in Preschoolers: Testing a Unique Service Delivery Model in American Indian Head Start Programs Principal Investigator: David Quissell, PhD. University of Colorado Anschutz Medical Center Colorado Native Oral Health Research (CNOHR)

2. Study Team Co-investigators Interventionists/COHS Stella Begay Helen Curley Nicole Garcia Tracy Goldtooth Rose Lee Lolita Spencer Nikola Toledo Cherise Watson • Judith Albino, PhD. • Terry Batliner, DDS. • Patty Braun, MD., MPH. • Lucinda Bryant, PhD. • Diana Cudeii, RDH. • Carmen George, MS. • Nicolas Johs, BA. • David Quissell, PhD. • Vong Smith, BA. • Nikola Toledo, MSA. • Others

3. Partnerships • Colorado School of Public Health • University of Colorado School of Medicine • University of Colorado School of Dentistry • Colorado Native Oral Health Research Program • Navajo Head Start • Navajo Nation Human Research Review Board

4. Early Childhood Caries • Dental caries in the primary teeth of children 0-6 years of age • Most common chronic disease of childhood • 5 times more common than asthma • Infectious disease • Largely preventable

5. Disparities • 79% of AI/AN preschool children have caries experience • 3 times greater than their non-Native counterparts • Navajo children have highest rates among American Indians • Mean number of dental surfaces = 19 • IHS not able to meet need

6. World Health Organization • Oral Health Promotion • “the process of enabling people to increase control over, and to improve their health” • “moving beyond a focus on individual behavior towards a wide range of social and environmental interventions” World Health Organization. 2010: http://www.who.int/topics/healthpromotion/en/

7. WHO Goals of Oral Health Promotion • Increase awareness of oral disease, its severity and factors that contribute to it • Reduce the number and intensity of risk factors for oral disease, e.g. reduce sugar intake • Decrease barriers to oral health, e.g. increase access to tooth-healthy foods • Increase access to prevention activities, e.g. fluoride varnish, dental visits • Create healthy environments, e.g. fluoridated water

8. Conceptual Framework

9. Theoretical Framework • Well-being of children depends primarily on the household production of health • the physical and social setting in which the child lives, • the customs of child care and child rearing regulated by the culture in which the setting is embedded, and • the psychology of the child’s caretakers Harkness S. Super CM. The developmental niche: a theoretical framework for analyzing the household production of health. SocSci Med. Jan 1994; 38(2): 217-226.

10. Study Setting • Navajo Head Start Centers • Federal program-105 HS Centers • Comprehensive child development program serving children ages 3-6 years and their families • Community-based, child-focused program • Overarching goal: increasing the social competence of young children in low-income families • Head Start performance standards

12. Study Design • Design: Phase 4 cluster randomized trial • Unit of analysis: Head start classroom • Intervention: fluoride varnish + parent oral health promotion education + classroom activities, delivered by Community Oral Health Specialists (COHS) • Control: usual care • Sample: 26 intervention classrooms + 26 usual care classrooms • Timing: 2 years of intervention; 3 years of data collection

13. Intervention • Structured for Academic Year • Quarterly Fluoride Varnish Application • Four Parent/Caregiver Events • Five Child Activities

14. Community Oral Health Specialist • Community Lay Health Worker • Oral Health Specialist • Child Educator • Parent Educator • Culturally Sensitive

15. Educational Strategy • Engage the Learner • informal conversations, storytelling • Active Learning • emphasize hands-on • Small Groups • encourage opportunities to interact • Application of Knowledge • practical applications • Appropriate Communication • culturally appropriate, ‘teach-back’ • Reinforcement • messages will be presented in a variety of formats, repeated

16. Curriculum • Curriculum targets many influences on disease process • Teeth • Fermentable carbohydrates • Bacteria • Parent/caregiver • Child • Head Start teacher

17. Curriculum- Messages • Improving oral health • Tooth brushing twice daily • Use fluoridated toothpaste • Drink fluoridated water • Fluoride varnish • Help child brush • Regular dental visits • Reducing fermentable carbohydrates • Reduce sugary/sticky foods • Reduce frequent snacking • More healthy snacks • Reduce vertical transmission of S. Mutans • Reduce oral sharing

18. Fluoride Varnish Application

19. Parent/Caregiver Events • Kick–Off event with parents/caregivers and children • Brings caregiver/child together • Incorporates Head Start classroom into the intervention • Engages the Head Start teacher into the process

20. Parent/Caregiver Events • Begins with an educational presentation to give necessary knowledge to empower caregivers to make change • Move to small group stations • Engaging • Hands on • Self goal setting • Follow up contact to assess progress on goal

21. Brief Educational Presentation HOLDING SPACE FOR PERMANENT TEETH! EATING! Baby Teeth are Importantfor: SPEAKING and SINGING! SMILING!

22. Small Group Stations

23. Caregiver Goal Setting Tool

24. Child Specific Sessions • Builds on primary concepts • Tooth function • Tooth brushing • Healthy eating • Fluoride • Dental visits • Short, fun activities • Coloring • Sorting games • Role playing • Matching games

25. Summary • Early childhood caries affects many Navajo children and is preventable • Innovative use of Community Oral Health Specialists • Directed toward the household production of health • Head Start classrooms • Theory-based curriculum

26. This research is supported by funding from the National Institute of Dental and Craniofacial Researchagreement #1U54DE019259-01.

27. Thank you!Ahéhee!