A COPC health intervention for kids in the Marys Center community

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A COPC health intervention for kids in the Marys
Center community

• Cheryl Focht, MD and Heather Cerar, RN
• Special Thanks to Duane Foster, Maria Gomez,
  Fitzhugh Mullan, Ben Gitterman, and the entire
  staff at Marys Center

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Marys Center Mission Statement
Provide holistic and culturally responsive health
care to women and their families, recognizing the
critical importance of the womans social
environment and emotional well being.
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Community Definition
Characterization
(Reassessment)
Prioritization
Evaluation
Detailed Assessment
Implementation
Intervention Planning
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Community Definition
All Latino children under the age of 19 years
old living in Ward 1
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Community Characterization
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Community Health Status Secondary Data Sources

• US Census- 1990 and 1997 Estimates
• District of Columbia Office of Planning
• District of Columbia Office of Maternal and Child
  Health
• District of Columbia Department of Health
• State Center for Health Statistics
• Council of Latino Agencies
• Marys Center for Maternal and Child Care
• Childrens National Medical Center
• DC Department of Tuberculosis Control

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Quantitative Data Collected

• Demographic
• Population
• Racial/Ethnic Breakdown
• Gender/age breakdown
• Marital Status
• Educational level/literacy rate
• Employment/income
• Housing

• Health Statistics
• Natality/Mortality
• Morbidity
• Prenatal Care
• Teen Pregnancy
• Immunization Rates
• HIV/STDs
• Nutrition/Obesity
• Health Insurance
• Mental Health
• Elevated lead
• Dental Caries

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Vital Health Statistics

• Infant Mortality Rates per 1000 live births
• Infant Mortality Rate for DC is 14.4
• Infant Mortality Rate for Latinos is incalculable
  due to such low numbers
• Prenatal Care
• 50 of DC Latinas did not receive prenatal care
  during their first trimester

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Low Birth Weight Percentages
(Percentage of all babies born, who weighed
under 5.5 pounds)

Percentage
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Teen Pregnancy

• The percentage of births to teenagers
  (13-19years)
• out of the total number of births
• 1993 data

• Marys Center Community 15
• District of Columbia 16
• United States 13.2

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Health Statistics

• HIV/AIDS
• In the District of Columbia, Latinos made up 4
  of the new AIDS cases reported in 1998
• (they comprise 8 of the total population)
• Sexually Transmitted Diseases
• In DC, rates among all teens are up 26 from
• 1996-1997

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Hospital Admissions to Childrens Hospital in DC

• Latinos
• Pneumonia
• Bronchiolitis
• Dehydration
• Perinatal Infection
• Urinary Tract Infection
• (Latino children made up 10 of admissions)

• African Americans
• Asthma
• Chemotherapy
• Pneumonia
• Bronchiolitis

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Immunization Rates

• Percentage of
• 2-year olds up to date on
• required immunizations (1996 data)
• Marys Center 96
• DC 65

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Oral Health

• In a 1995 dental screening in our community, 45
  of children ages two to five years were found to
  have dental caries.
• 1999 CSNAP Survey at Marys Center
• (Childrens Sentinel Nutrition Assessment
  Program)
• 90 of Latino children did not have regular
  dental visits
• 29 did not practice recommended dental hygiene

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Nutritional Status

• At Marys Center...
• In 1995, 5 of children ages six months to five
  years were diagnosed as failure to thrive
• In 1998, over 20 of children ages one to eight
  were diagnosed as obese

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Health Insurance Coverage at Marys Center(1996
data)
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Qualitative Data Sources

• Key Informants
• Pharmacist
• Pediatrician
• Teen Program Director
• Day Care Center Director
• Social Worker
• Radio Show Host
• Community Educator
• Clinic Receptionist

• Focus Groups
• Even Start Program Educators
• Community Agency Staff
• Community Parents
• Marys Center Staff

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Community Comments

• Definition of health If the child eats, smiles
  and plays hes healthy.
• Who is your community I like the centers of
  help, becausethey make you feel like you are not
  alone.
• Strengths of the community strength of the
  people, commitment to family
• Barriers in receiving health care ser Hispano
  (todo esto) es un problema and No poder
  communicarle con el doctor lo que tiene el nino
• Common problems in health care Providers need
  to adapt their care based on the health care
  needs of the community

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Identified Health Care Problems of Children
in Our Community

• Decreased access to well child care
• Poor parental understanding of normal development
• Parental perception for use of medication
• Lack of available services for diagnosis and
  treatment of learning behavioral problems
• Lack of knowledge about community services

• Teenage pregnancy
• Nutritional Problems/Obesity
• Tuberculosis
• HIV/AIDS
• Asthma
• Anemia
• Elevated lead levels
• Suicide and Depression
• School Dropouts
• Dental caries/poor oral health

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Prioritization
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Step 1 Community Team

• Participants members and directors of community
  agencies, a parent in the community, and two
  members of the Marys center staff.
• Activities presentation of characterization
  data, discussion of community issues, individual
  ranking of top five health issues.
• Outcome
• AIDS/HIV
• Nutritional Problems
• Lack of available services for diagnosis and
  treatment of learning and behavioral disorders
• Lack of parental education
• Poor oral health/caries

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Step 2 Clinic Staff

• Participants all staff members of Marys Center
• Activities presentation of characterization
  data, scoring of five health problems selected by
  community prioritization team
• Criteria used
• Magnitude
• Community concern
• Efficacy of an intervention
• Resources needed
• Sustainability of an intervention

Outcome DENTAL CARIES
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Detailed Assessment
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Assessing the Problem

• Literature Search
• Background Information
• Research
• Programs
• Discussion with Experts/Researchers in the Field
• Discussion with Community Collaborators
• Primary Data Collection

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Dental Caries - Literature Search

• Early childhood caries (ECC) is defined as one or
  more carious lesions involving maxillary anterior
  teeth in a child under three years.
• Prevalence
• US overall 5
• Developing countries 20
• US inner city immigrants and Native Americans 50

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CAUSES OF ECC


Substrate (sugars)

Bacteria (S. mutans)

• Caries model
• Behavioral practices
• Cultural beliefs/ practices
• Socioeconomic aspects

CARIES
Susceptible tooth
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High Risk Behaviors

• Mothers dental hygiene
• Passive child rearing/overindulgent parents
• Inappropriate feeding practices
• Frequent bottle use
• At will breast or bottle feeding
• Nighttime bottle use (sugar pools around teeth)
• Prolonged bottle use after normal weaning
• Inadequate dental hygiene (brushing, fluoride
  toothpaste, regular dental visits)

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Contributors to Caries in Our Population

• Behaviors
• Poor hygiene (maternal and child)
• Bottle misuse
• High frequency bottle or breast feeding
• Nighttime bottle use
• Prolonged bottle use after normal weaning
• Cultural Influences
• Baby teeth are unimportant
• Home tooth cleaning remedies
• Desire to have healthy chubby babies
• Passive childrearing/overindulgence
• Socioeconomic Issues Barriers to dental visits

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Environmental Risk Factors

• Race/Ethnicity
• Culture
• Socioeconomic status
• Stress
• Health care delivery and access

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Discussions with Dental Caries Experts

• Three nationally renowned dental caries
  researchers
• A pedodontist working with the Federal government
  to reduce dental caries
• Director of pediatric dentistry at Childrens
  Hospital in DC
• Local pedodontist, caries researcher and
  community advocate for Latino children
• Local dentists
• Several national dental organizations

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Primary Data Collection
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Intervention Planning
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What is being done?
Preventive Activities
City Level Medicaid Free
dental clinics
Community Level Dentists in Pediatric
clinics Low cost dental work Prior intervention
Federal Level Fluoridated water AAPD
Guidelines NHANES Study NIH Research Community
Interventions Healthy People 2000
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What needs to be done?

• Recognize the problem as a major public health
  issue
• Prevention. Prevention. Prevention. With a focus
  on the prenatal period and the first year of
  life.
• Encourage involvement of primary care providers
  and train dental providers to work effectively
  with children.
• Train all health care providers about the current
  guidelines for oral hygiene
• Provide access to preventative dental services
  for all children.

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The Intervention
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Program Objectives

• Increase the knowledge of parents about cleaning
  infants mouths and brushing childrens teeth.
• Increase the number of parents of children under
  age 1 who clean their childs teeth.
• Increase the number of parents who know that tap
  water is a source of fluoride.
• Increase the number of children drinking tap
  water.
• Decrease the number of children drinking from the
  bottle past one year of age.
• Increase the number of parents who know which
  beverages and foods most commonly cause cavities.
• Increase the number of children who have had
  their first dental visit before the age of 2
  years.
• Increase access to preventative dental care.

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Educational Activities

• 1. Initial training with Marys Center Staff
• 2. Preventive dental program integrated into
  existing prenatal classes.
• 3. Integration of oral health on the well child
  forms used at each visit.

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Hands-On Activities

• Posters in each exam room. (foods to avoid,
  proper snacks, bottle use, dental hygiene)
• Picture brochures to hand out at the 6 month
  visit regarding proper dental hygiene.
• Local dentist to come in during playgroup to
  talk to parents about routine dental care.
• Referral source of local dentists.
• Bottle exchange
• Handing out toothbrushes and toothpaste
• Radio campaign

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Program Evaluation
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Surveillance

• Chart Reviews
• Oral heath practices of families
• Marking of dental anticipatory guidance boxes
• Clinic Staff Feedback
• Numbers of toothbrushes, cups, brochures and
  stickers given out

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Evaluation

• Oral Health Knowledge and Behavior Survey
  re-administered to parents 2 years after program
  implementation.
• Documentation of prevalence of early childhood
  caries among target population after 3-5 years of
  program.

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Future Directions

• Oral Health at Marys Center
• Collaborations with neighborhood dental offices
  and dental departments at local hospitals to
  increase the safety net of dental providers
  within the community.
• Dissemination of program to other community
  clinics.
• Grant funding to maintain oral health supplies
  within the clinic.
• Focusing on parental oral health.
• Future projects reassessment and
  reprioritization of a health care issue to target.

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Dental problems have the consequences of wearing
down the stamina of children and defeating their
ambitions. Bleeding gums, impacted teeth and
rotting teeth are routine matters for these
children. They get used to feeling the constant
pain. They go to sleep with it. They go to
school with it. Children live for months with
pain that grown ups would find unendurable. The
gradual attrition of accepted pain erodes their
energy and aspirations. I have seen children
with teeth that look like brownish broken sticks.
But to me, most shocking is to see a child with
an abscess that has been inflamed for weeks and
that he has simply to live with and accepts as
part of the routine of life.

- J. Kozol