Patricia A. Braun

Immunization Registry Accuracy Improvement with Progressive Clinical Application

BACKGROUND Healthcare systems have been challenged to ensure the timely administration of immunizations. Immunization registries have been proposed to improve the accuracy and completeness of immunization information and to promote effective practice. METHODS Comparison of randomly selected samples from two birth cohorts (1993 and 1998) from Denver Health Medical Center. Chart review and immunization registry information for these groups were compared; a composite immunization was recorded and up-to-date (UTD) status established. Registry data were compared with this composite using a sensitivity measure to assess completeness and accuracy. RESULTS Among 818 children in the 1993 cohort and 1043 children in the 1998 cohort, there were 6386 and 6886 valid immunizations, respectively. The registry recorded 71.4% and 97.7% of these for the 1993 and 1998 cohorts, respectively (p <0.001). The apparent UTD rate, as measured with registry data alone, improved from 37% to 79% between the two time frames (p <0.001). Composite UTD status was 83.1% and 78.9% (1993 vs 1998, respectively). Accurate registry-defined UTD status improved from 44.4% to 100% between the two intervals. CONCLUSIONS Immunization registry accuracy improved dramatically for recorded immunizations and UTD status. However, after 3 years of registry use, the overall proportion of children who were UTD had not significantly improved. The mere presence of a registry does not ensure more complete vaccination coverage. Other registry-based strategies, including use of the data for reminder, recall, and audit, may further improve immunization coverage.

A Cluster-Randomized, Community-Based, Tribally Delivered Oral Health Promotion Trial in Navajo Head Start Children

The authors tested the effectiveness of a community-based, tribally delivered oral health promotion (OHP) intervention (INT) at reducing caries increment in Navajo children attending Head Start. In a 3-y cluster-randomized trial, we developed an OHP INT with Navajo input that was delivered by trained Navajo lay health workers to children attending 52 Navajo Head Start classrooms (26 INT, 26 usual care [UC]). The INT was designed as a highly personalized set of oral health–focused interactions (5 for children and 4 for parents), along with 4 fluoride varnish applications delivered in Head Start during academic years of 2011 to 2012 and 2012 to 2013. The authors evaluated INT impact on decayed, missing, and filled tooth surfaces (dmfs) increment compared with UC. Other outcomes included caries prevalence and caregiver oral health–related knowledge and behaviors. Modified intention-to-treat and per-protocol analyses were conducted. The authors enrolled 1,016 caregiver-child dyads. Baseline mean dmfs/caries prevalence equaled 19.9/86.5% for the INT group and 22.8/90.1% for the UC group, respectively. INT adherence was 53% (i.e., ≥3 child OHP events, ≥1 caregiver OHP events, and ≥3 fluoride varnish). After 3 y, dmfs increased in both groups (+12.9 INT vs. +10.8 UC; P = 0.216), as did caries prevalence (86.5% to 96.6% INT vs. 90.1% to 98.2% UC; P = 0.808) in a modified intention-to-treat analysis of 897 caregiver-child dyads receiving 1 y of INT. Caregiver oral health knowledge scores improved in both groups (75.1% to 81.2% INT vs. 73.6% to 79.5% UC; P = 0.369). Caregiver oral health behavior scores improved more rapidly in the INT group versus the UC group (P = 0.006). The dmfs increment was smaller among adherent INT children (+8.9) than among UC children (+10.8; P = 0.028) in a per-protocol analysis. In conclusion, the severity of dental disease in Navajo Head Start children is extreme and difficult to improve. The authors argue that successful approaches to prevention may require even more highly personalized approaches shaped by cultural perspectives and attentive to the social determinants of oral health (ClinicalTrials.gov NCT01116739).

Oral health status in Navajo Nation Head Start children

OBJECTIVE This study assessed oral health status for preschool-aged children in the Navajo Nation to obtain data on baseline decayed, missing, and filled tooth surfaces (dmfs) and dental caries patterns, describe sociodemographic correlates of childrens baseline dmfs measures, and compare the childrens dmfs measures with previous dental survey data for the Navajo Nation from the Indian Health Service and the National Health and Nutrition Examination Survey (NHANES). METHODS The analyzed study sample included 981 child/caregiver dyads residing in the Navajo Nation who completed baseline dmfs assessments for an ongoing randomized clinical trial involving Navajo Nation Head Start Centers. Calibrated dental hygienists collected baseline dmfs data from child participants ages 3-5 years (488 males and 493 females), and caregivers completed a basic research factors questionnaire. RESULTS Mean dmfs for the study population was 21.33 (SD=19.99) and not appreciably different from the 1999 Indian Health Service survey of Navajo Nation preschool-aged children (mean=19.02, SD=16.59, P=0.08). However, only 69.5 percent of children in the current study had untreated decay compared with 82.9 percent in the 1999 Indian Health Service survey (P<0.0001). Study results were considerably higher than the 16.0 percent reported for 2-4-year-old children in the whites-only group from the 1999-2004 NHANES data. Age had the strongest association with dmfs, followed by child gender, then caregiver income and education. CONCLUSION Dental caries in preschool-aged Navajo children is extremely high compared with other US population segments, and dmfs has not appreciably changed for more than a decade.

Preventing caries in preschoolers: Successful initiation of an innovative community-based clinical trial in Navajo Nation Head Start ☆

UNLABELLED Navajo Nation children have the greatest prevalence of early childhood caries in the United States. This protocol describes an innovative combination of community-based participatory research and clinical trial methods to rigorously test a lay native Community Oral Health Specialists-delivered oral health intervention, with the goal of reducing the progression of disease and improving family knowledge and behaviors. METHODS/DESIGN This cluster-randomized trial designed by researchers at the Center for Native Oral Health Research at the University of Colorado in conjunction with members of the Navajo Nation community compares outcomes between the manualized 2-year oral health fluoride varnish-oral health promotion intervention and usual care in the community (child-caregiver dyads from 26 Head Start classrooms in each study arm; total of 1016 dyads). Outcome assessment includes annual dental screening and an annual caregiver survey of knowledge, attitudes and behaviors; collection of cost data will support cost-benefit analyses. DISCUSSION The study protocol meets all standards required of randomized clinical trials. Aligned with principles of community-based participatory research, extended interaction between members of the Navajo community and researchers preceded study initiation, and collaboration between project staff and a wide variety of community members informed the study design and implementation. We believe that the benefits of adding CBPR methods to those of randomized clinical studies outweigh the barriers and constraints, especially in studies of health disparities and in challenging settings. When done well, this innovative mix of methods will increase the likelihood of valid results that communities can use.

Feasibility of colocating dental hygienists into medical practices

OBJECTIVES To test the feasibility of colocating registered dental hygienists (RDHs) into medical practices and to evaluate parent/caregiver oral health characteristics. METHODS From December 2008 to April 2009, we colocated five RDHs into five medical practices identified for their service to low-income children. Dual-function exam rooms were built in each office. Caregiver-child dyads were recruited from the practices for program evaluation. We used both qualitative (key informant interviews) and quantitative (survey) methods to evaluate the project. Feasibility was measured by assessment of RDH and practice factors that facilitated and/or created barriers to colocation, sustainability of services 5 years after colocation, and caregiver satisfaction with services. Caregiver oral health knowledge, attitudes, beliefs, and behaviors were also measured. RESULTS Over 27 months, five part-time RDHs provided care to 2,071 children. Children of caregiver-child dyads (n = 583) recruited for evaluation were young (mean age = 1.8 years), white (46 percent), non-Hispanic (56 percent), and publicly insured (68 percent Medicaid/11 percent State Childrens Health Insurance Plan). Key informant interviews revealed various factors that facilitated and created barriers to program adoption, implementation, and sustainability. Most barriers were overcome. Five RDHs remained in the practices 2 years after program initiation and four remained after 5 years. At 1 year, 27 percent of caregiver-child dyads returned for evaluation and were highly satisfied with services. Caregivers reported favorable oral health characteristics and few barriers to receiving preventive dental care at baseline and 1-year follow-up. CONCLUSIONS Colocating RDHs into medical practices is feasible and an innovative model to provide preventive oral health services to disadvantaged children.

Learning from caries‐free children in a high‐caries American Indian population

OBJECTIVE We aimed to identify salutogenic patterns of parental knowledge, behaviors, attitudes, and beliefs that may support resistance to early childhood caries (ECC) among a high caries population of preschool American Indian (AI) children. METHOD Participants were 981 child-parent dyads living on a Southwestern reservation who completed baseline assessments for an ongoing randomized clinical trial. T-tests were used to assess differences between reported knowledge, behaviors, and beliefs of parents whose children were caries-free (10.7 percent) and those whose children had caries (89.3 percent). Chi-square analyses were used for categorical variables. RESULTS Although there were no socio-demographic differences, parents of caries-free children viewed oral health as more important and reported more oral health knowledge and adherence to caries-preventing behaviors for their children. Parents of caries-free children were more likely to have higher internal locus of control, to perceive their children as less susceptible to caries, and to perceive fewer barriers to prevention. These parents also had higher sense of coherence scores and reported lower levels of personal distress and community-related stress. CONCLUSIONS Effective interventions for ECC prevention in high-caries AI populations may benefit from approaches that support and model naturally salutogenic behaviors.

Retention strategies for health disparities preventive trials: findings from the Early Childhood Caries Collaborating Centers

OBJECTIVES To identify successful strategies for retention of participants in multiyear, community-based randomized controlled trials (RCTs) aiming to reduce early childhood caries in health disparities populations from diverse racial/ethnic backgrounds and across diverse geographic settings. METHODS Four RCTs conducted by the Early Childhood Caries Collaborating Centers (EC4), an initiative of the National Institute of Dental and Craniofacial Research, systematically collected information on the success of various strategies implemented to promote participant retention in each RCT. The observational findings from this case series of four RCTs were tabulated and the strategies rated by study staff. RESULTS Participant retention at 12 months of follow-up ranged from 52.8 percent to 91.7 percent, and at 24 months ranged from 53.6 percent to 85.9, across the four RCTs. For the three RCTs that had a 36-month follow-up, retention ranged from 53.6 percent to 85.1 percent. Effectiveness of different participant retention strategies varied widely across the RCTs. CONCLUSIONS Findings from this case series study may help to guide the design of future RCTs to maximize retention of study participants and yield needed data on effective interventions to reduce oral health disparities.

Effectiveness on Early Childhood Caries of an Oral Health Promotion Program for Medical Providers

Objectives To assess an oral health promotion (OHP) intervention for medical providers’ impact on early childhood caries (ECC). Methods We implemented a quasiexperimental OHP intervention in 8 federally qualified health centers that trained medical providers on ECC risk assessment, oral examination and instruction, dental referral, and fluoride varnish applications (FVAs). We measured OHP delivery by FVA count at medical visits. We measured the intervention’s impact on ECC in 3 unique cohorts of children aged 3 to 4 years in 2009 (preintervention; n = 202), 2011 (midintervention; n = 420), and 2015 (≥ 4 FVAs; n = 153). We compared numbers of decayed, missing, and filled tooth surfaces using adjusted zero-inflated negative binomial models. Results Across 3 unique cohorts, the FVA mean (range) count was 0.0 (0), 1.1 (0-7), and 4.5 (4-7) in 2009, 2011, and 2015, respectively. In adjusted zero-inflated negative binomial models analyses, children in the 2015 cohort had significantly fewer decayed, missing, and filled tooth surfaces than did children in previous cohorts. Conclusions An OHP intervention targeting medical providers reduced ECC when children received 4 or more FVAs at a medical visit by age 3 years.

Validity of Measures Assessing Oral Health Beliefs of American Indian Parents

ObjectivesThis aimed to validate measures of constructs included in an extended Health Belief Model (EHBM) addressing oral health beliefs among American Indian (AI) parents.MethodsQuestionnaire data were collected as part of a randomized controlled trial (n = 1016) aimed at reducing childhood caries. Participants were AI parents with a preschool-age child enrolled in the Navajo Nation Head Start program. Questionnaire items addressed five EHBM constructs: perceived susceptibility, severity, barriers, benefits, and parental self-efficacy. Subscales representing each construct underwent reliability and validity testing. Internal consistency reliability of each subscale was evaluated using Cronbach’s alpha. Convergent validity was assessed using linear regression to evaluate the association of each EHBM subscale with oral health-related measures.ResultsInternal consistency reliability was high for self-efficacy (α = 0.83) and perceived benefits (α = 0.83) compared to remaining EHBM subscales (α < 0.50). Parents with more education (p < 0.0001) and income (p = 0.0002) perceived dental caries as more severe younger parents (ps = 0.02) and those with more education (ps < 0.0001) perceived greater benefits and fewer barriers to following recommended oral health behavior. Female parents (p < 0.0001) and those with more education (p = 0.02) had higher levels of self-efficacy. Parental knowledge was associated with all EHBM measures (ps < 0.0001) excluding perceived susceptibility (p > 0.05). Parents with increased self-efficacy had greater behavioral adherence (p < 0.0001), whereas lower behavioral adherence was associated with parents who reported higher perceived barriers (p < 0.0001). Better pediatric oral health outcomes were associated with higher levels of self-efficacy (p < 0.0001) and lower levels of perceived severity (p = 0.02) and barriers (p = 0.05).ConclusionsResults support the value of questionnaire items addressing the EHBM subscales, which functioned in a manner consistent with the EHBM theoretical framework in AI participants.