An Interdisciplinary Approach to Oral Health Promotion: AR 60063 and the Community Health Promotion

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An Interdisciplinary Approach to Oral Health
Promotion AR 600-63 and the Community Health
Promotion Council

• LTC Georgia dela Cruz, DMD, MPH

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Purpose

• Provide an overview of AR 600-63 Army Health
  Promotion Regulation and the Community Health
  Promotion Council (CHPC), discuss the value of
  collaborative partnerships in health promotion
  efforts, and provide examples of recruitment and
  integration of partners from various disciplines.
  

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Outline

• Introduction to AR 600-63
• Objectives and scope of Army Health Promotion
  Programs
• Responsibilities
• Overview of Functional Areas
• The Community Health Promotion Council-Implementat
  ion Guidance
• Collaborative Partnerships
• Multidisciplinary Recruitment
• Summary and Review
• Questions

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Army Health Promotion ProgramGoal and Objectives

• Goal maximize readiness, warfighting ability,
  and work performance.
• Objectives
• Enhancing the well-being of all Soldiers, Army
  civilians, Family members, and retirees
• Encouraging lifestyles that improve and protect
  physical, behavioral, and spiritual health.

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Scope

• Facilitate behavioral and environmental
  alterations
• Include directives from the Army Surgeon General,
  Healthy People 2010 objectives, to include
• Physical and dental examinations
• Self-reported health information
• Physical fitness facilities
• Recreation and leisure education
• Activities and initiatives to promote social and
  emotional well-being

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Chapter 1

• Introduction to AR 600-63
• Prescribes policy, responsibilities, and
  procedures for the Army Health Promotion Program
• Defines Army Health Promotion
• Outlines five functional areas for health
  promotion programs
• Establishes policy for tobacco control for the
  Department of the Army

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Army Health Promotion Definition

• Any combination of health education and related
  organizational, political, and economic
  interventions designed to facilitate behavioral
  and environmental changes conducive to the health
  and well-being of the Army community. Health is
  the product of many personal, environmental, and
  behavioral factors.

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Health Promotion Concepts

• Four major factors that affect health
• Behavior/lifestyle
• Environmental factors (social, physical, and
  economic)
• Human biology
• Medical Services Health Care system

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Figure 11. Health-related factors

• Health promotion programs must consider a broad
  range of health-related factors and should
  address the following functional areas

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Army Health Promotion

• Similar to the composite risk management (CRM)
  process (FM 519)
• Risk management definition - the process of
  identifying, assessing, and controlling risks
  arising from operational factors and making
  decisions that balance risk costs with mission
  benefits.

Identifying, assessing, and controlling health
risks arising from operational factors and making
decisions that balance health risk costs with
well-being.
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Figure 12. CRM Process

• Command supervision and enforcement of
  interventions is critical.
• Reassessment enables determination of success or
  adjustments as needed.

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Army Health Promotion

• Is implemented and enhanced at the community
  level through a Community Health Promotion
  Council (CHPC), as provided for in the regulation
• Involves
• Identifying community health needs and setting
  priorities.
• Developing and implementing health promotion
  programs to meet identified needs.
• Evaluating the effectiveness of these programs.

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Responsibilities

• DCS G-1
• DCS G-3
• DCS G-4
• TSG
• CPA
• CCH
• JAG
• COE
• Chief NGB

• USAR
• CG - USACHPPM
• CG CFSC
• CG TRADOC
• MACOM Commanders
• Installation Commanders
• MEDCEN/MEDDAC Commanders
• Commanders at all levels

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DCS, G-1 Responsibilities

• Army Staff proponent for
• Army Health Promotion Program policy and
  implementing Department of Defense Directive
  (DODD) 1010.10.
• Army Substance Abuse Program (ASAP).
• Tobacco Control Program.
• Army Weight Control Program.
• Suicide prevention, to include coordination and
  monitoring of the Army Suicide Prevention Program
  (ASPP).
• Identification, surveillance, and administration
  of personnel infected with Human Immunodeficiency
  Virus (HIV).

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USACHPPM Responsibilities

• Recommend Army Health Promotion policy
  implementation and change.
• Define the role and identify training
  requirements and training opportunities for
  Health Promotion Coordinators in support of
  CHPCs.
• Develop and disseminate standardized,
  evidence-based programs and tools.
• Serve as a consultant for the development of
  population-based comprehensive and integrated
  military health information systems.
• Develop science-based metrics for program
  evaluation and health promotion outcomes.
• Provide subject matter expert (SME) consultation,
  education, and training for Army Health Promotion
  programs and CHPCs.
• Serve as an information source for current issues
  and best practices for health promotion
  initiatives.
• Provide recommendations for population- and
  community-based research.

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Chapter 2

• Community Health Promotion Program
• Implementation guidance
• Effective, comprehensive and integrated program
  at the installation, community, and garrison
  leader levels is key
• USACHPPM serves as health promotion advisor and
  consultant for Army Health Promotion Program
• Community Health Promotion Council
• Initiate preventive interventions that directly
  impact the total population
• Assist, develop, and implement means to allow
  commanders to monitor program goals and
  objectives.
• Ensure necessary health promotion knowledge,
  skills, and training will be available for the
  community.

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CHPC Membership

• Installation commander or community leader.
• Health Promotion Coordinator.
• Senior mission/garrison command sergeant major.
• Director, Human Resources Directorate (Civilian
  Personnel Advisory Center, Military Personnel
  Services, Education, and Alcohol and Drug Control
  Officer).
• Family Advocacy Program Manager (FAPM).
• Commander, MTF.
• Director of Logistics.
• Director for Plans, Training, and Mobilization.
• Commander, Dental Activity/Director of Dental
  Services.
• Staff Chaplain.
• Public Affairs Officer.
• Major tenant commanders.
• Consultants, as needed. For example, this
  category could include representatives from the
  installation safety, public affairs, and civilian
  personnel offices ASAP, medical/dental/
  veterinarian,

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CHPC Administration

• CHPC chairperson - commander, community leader,
  or designee from the command group
• Community Health Promotion Coordinator - provides
  logistical and advisory support to the commander
  and the CHPC
• CHPC will convene at least quarterly
• CHPC members serve for a minimum of 1 year,
  subject to reappointment

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CHPC Roles

• Principal tasks
• Assess community needs
• Analyze the data
• Inventory resources
• Develop, implement, and evaluate a course of
  action to address identified community needs
• Integrate all existing health promotion programs
  with other installation and community programs
• Develop a comprehensive marketing plan based on
  existing resources and demographics
• Report progress, challenges and successes to the
  Community Well-Being Council as defined by IMA

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CHPC Roles

• Integration of Collaborative partnerships among
  community agencies
• Enhances knowledge, experience, resources
• Minimizes duplication of efforts.
• Include potential community partners, such as
  local and state health departments, school
  systems, and organizations (American Red Cross,
  American Heart Association, etc.)

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Functional Areas

• Health education/health promotion process
• Behavioral health interventions
• Physical programs
• Spiritual programs
• Environmental social programs

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Chapter 3

• Health Education/Health Promotion Process
• A planned process that promotes, maintains, and
  improves individual, Family, and community health
  by raising awareness, enhancing knowledge, and
  inspiring readiness to change through healthy
  lifestyle choices.
• Framework - assessment, planning, implementation,
  evaluation, and communication of health
  information needs and resources.
• Resources

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Chapter 4

• Behavioral Health
• General
• Stress management
• Combat and operational stress control
• Suicide prevention and surveillance
• Responsible sexual behavior
• Army Substance Abuse Program
• Tobacco Control Program

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Tobacco Control Program

• Tobacco use controlled during IET
• Commanders supervisors encourage anti-tobacco
  activities by Family Members Retirees
• Screen for tobacco use during all routine exams
  and refer for cessation assistance
• Installations will provide tobacco cessation
  programs for all health care beneficiaries and as
  resources permit, for civilian employees.

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Chapter 5

• Physical Health
• General
• Fitness and Health Program
• Injury prevention
• Ergonomics
• Oral health
• Nutrition
• Weight management

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Injury Prevention

• Unit Commanders will
• Foster a culture of injury risk reduction
• Coordinate with the medical/dental treatment
  facility commander to receive SME consultation
  regarding all unit staff functions related to
  injury prevention (such as dental readiness
  meetings and appropriate use of mouthguards.)

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Oral Health

• Includes all initiatives to
• Increase the overall fitness and dental readiness
  of Soldiers,
• Reduce the incidence of dental disease in the
  community
• Identify community members in need of dental
  treatment
• Direct members to sources of appropriate care.

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Oral Health

• Dental Readiness Program
• Clinical Oral Health and Dental Health Promotion
  Program
• Community Oral Health Promotion and Disease
  Prevention Program

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Dental Readiness Program

• Annual Examination required
• Encourage Soldiers to maintain Dental Fitness
  Class 1 (Dental Wellness)
• Minimum readiness standard Dental Fitness Class
  2
• Dental Fitness Class 3 or 4 are non-deployable
• Commanders will require and enforce mouthguard
  use during certain training or unit sports
  activities

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Clinical Oral Health and Dental Health Promotion
Program

• Screenings
• Hypertension, oral disease risks, orofacial
  injury risk, family abuse
• Dental Classification
• Oral prophylaxis (dental cleaning)
• Fluoride prescription
• Counseling as appropriate
• Hygiene, nutrition, tobacco
• Mouthguard fabrication
• Dietary counseling referral

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Community Oral Health Promotion and Disease
Prevention Program

• Fluoridation of community water supplies
• Alternative fluoride administration
• Community education programs
• School-based programs
• System for reporting child neglect or abuse

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Oral Health

• Proponent for oral health ensures community oral
  health promotion carried out
• CDR or CHPC may designate PAT to review Oral
  Health Promotion activities
• Ensure PAT membership is cross-sectional

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Nutrition

• WHY
• Resources
• Opportunities
• CHPC role

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Nutrition Resources

• Collaborative Assets
• The Army Registered Dietitian (65C)
• The Army Nutrition Care Specialist (91M)
• Army Regulations
• AR 40-25
• AR 30-1
• AR 600-9

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Nutrition Opportunities

• Healthy Weight Management
• Dietary Supplement Usage
• http//usachppm.apgea.army.mil/dhpw/Wellness/dieta
  ry.aspx
• Food Safety
• Meal Planning
• Special nutrition concerns
• Elevated Blood Sugar
• Cholesterol
• Blood Pressure

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Community Health Promotion Councils Role in
Nutrition

• Use RD as valued consultant
• Multidisciplinary Team Member
• Nutrition Experts and Clinicians
• Market Experts
• Evidenced Based and Outcomes Oriented
• Encourage use of distance learning opportunities
• Ensure community educational programs are offered
• Support nutrition related efforts of installation
  and MTF commander

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Weight Management

• Is weight a health risk?
• compromised performance and readiness
• decreasing injuries
• health benefits
• Underweight/ Overweight
• Strategies and Resources
• CHPC Role

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Both Sides Matter

• Underweight
• Disease Process
• Anorexia/ Bulimia
• Overweight and Obesity
• Risks of Overweight and Obesity
• Improved Readiness

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Chapter 6

• Spiritual Fitness
• General
• Spiritual fitness

Strong Bonds Battlemind Training Spiritual
Health Assessment Instrument Blue Box (Initiative
at USAEUR) Suicide Prevention, Intervention, and
Postvention programs
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Chapter 7

• Environmental Health
• General
• Guidance for controlling tobacco use in DA
  controlled areas
• Policy for controlling tobacco use
• Signs for controlling tobacco use
• Enforcement for controlling tobacco use

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Environmental Health Programs

• Goals
• Create and maintain a supportive, safe, and
  healthy environment
• Protect from biological, chemical and physical
  hazards
• Secure from adverse effects of environmental
  threats

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Environmental Health Programs

• Pro-active public health policies
• Reduce risk from environmental exposures and
  encourage healthy lifestyles.

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Environmental Health Programs

• Tobacco use is prohibited in all DA-occupied
  workplaces to include recreation facilities
  except for designated smoking areas as authorized
  by DODI 1010.15, Smoke-Free DoD recreation
  Facilities
• Use of all Tobacco products is prohibited in all
  military vehicles and aircraft and all official
  vans and buses
• Health care providers will not use any tobacco
  products in the presence of patients

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Environmental Health Programs

• Future trends in tobacco control
• Tobacco use is a high visibility issue. Use is on
  the rise
• TRADOC has lifted ban in AIT (increased
  opportunities for interventions)
• Current research partnerships with Research
  Triangle Institute (RTI)
• Social norming campaigns hold promise

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Collaboration/Community Partnerships

• Enhance
• Knowledge
• Experience
• Resources
• Minimize duplication of efforts
• Healthy People 2010

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Collaboration/Community Partnerships

• Improve not only health but other areas as well
• Empower individuals
• Tailor approaches
• Multidisciplinary approach

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Collaboration/Community Partnerships

• Characteristics for Success
• Being informed
• Flexibility
• Negotiation

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Example of an Integrated Approach to a Community
Health Problem
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Early Childhood Caries

• AER financial aid request
• Pediatrician at MTF
• About 1 out of 6 children under the age of 5 have
  untreated tooth decay
• About twice a month she sees a child that has
  extensive decay
• Many have had at least one visit to the emergency
  room.

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Phase 1
Phase 4 Phase 3
Phase 2 Phase 1
Administrative
Educational Epidemiological
Social policy
assessment ecological
assessment assessment
and Intervention
assessment
alignment
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Phase 2
Phase 4 Phase 3
Phase 2 Phase 1
Administrative
Educational Epidemiological
Social policy
assessment ecological
assessment assessment
and Intervention
assessment
alignment
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Phase 2 Epidemiological Assessment

• Genetics
• Developmental defects of enamel
• Poor quality saliva
• Poor resistance
• Early eruption

• Environment
• Water fluoridation
• Access to dental care
• Community awareness

• Behavior
• Sharing practices
• Feeding practices
• Snacking behavior
• Oral habits

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Phase 3
Phase 4 Phase 3
Phase 2 Phase 1
Administrative
Educational Epidemiological
Social policy
assessment ecological
assessment assessment
and Intervention
assessment
alignment
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Phase 3

• Predisposing Factors
• Oral health knowledge
• Perception of the value of oral health
• Belief in the effectiveness of preventive
  practices
• Family values

• Enabling Factors
• Fluoridated water
• Availability of oral health care products
• Relative cost
• Oral hygiene Skills
• Stress

• Reinforcing Factors
• Rewards feedback
• Attitudes behaviors
• Health care personnel
• Peers
• Parents

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Phase 4
Phase 4 Phase 3
Phase 2 Phase 1
Administrative
Educational Epidemiological
Social policy
assessment ecological
assessment assessment
and Intervention
assessment
alignment
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Phase 4 Health Education

• Increase access to dental treatment
• Reduce sugar exposure
• Timing and frequency
• Healthy snack choices
• Decrease sugared beverage consumption
• Decrease bacteria
• Eliminate sharing practices
• Correct oral hygiene aids
• Xylitol gum
• Increase fluoride intake
• Toothpaste
• Water
• Supplements

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Range of Disciplines
Pediatrician
Laboratory technician
DeCA Manager
Audiologist
Family Practice Physician
Optometrist
Army Community Service
TRICARE
Physicians Assistant
AAFES Manager
Child and Youth Services
Dental Clinic
Social Worker
Chaplain
Nurse Practitioner
Dietitian
Public Health Nurse
Psychologist
Preventive Medicine Physician
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Phase 4 Policies and Regulations
Stakeholders/Contact Opportunities

• TRICARE - bulletins
• ACS
• Women, Infants and Children Program (WIC)
• New Parent Support Program (NPSP)
• Family Advocacy Program
• SITES
• CYS CDC/FCC
• AAFES community events
• Commissary Healthy Choices

• Unit Commanders-orientation
• Family Readiness Groups (FRGs)-social events
• OB/FP- Prenatal counseling
• Peds-Well-child visits and immunizations
• Dental Clinic annual exam
• United Concordia TRICARE Dental Program (TDP)
• Army Emergency Relief

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Phase 4 Intervention Alignment

• Increase access to dental care

Providers (Pediatrician, Family Practice, NP, PA)
Dental Officer
Unit
RAP
TDP
SWS
Civilian dental treatment
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Phase 4 Intervention Alignment

• Reduce sugar exposure
• Decrease bacteria

Dental Officer
Dietician
CYS CDC/FCC
ACS WIC/NPSP
TRICARE
FRGs
Commissary/AAFES
Healthy snacks/drinks Regular Oral Hygiene
Providers (Pediatric and OB)
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Phase 4 Intervention Alignment

• Increase fluoride intake

Dental Officer
FRGs
DPW
ACS WIC/NPSP
Commissary/AAFES
Providers (Pediatrician, Family Practice, NP, PA)
Acid-resistant teeth
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Phase 4 Intervention Alignment

• What interventions are needed most?
• Health Education
• Policy development
• Which ones can the community support?

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Collaboration/Community Partnerships

• Potential Partners
• The US Army Center for Health Promotion and
  Preventive Medicine http//chppm-www.apgea.army.
  mil
• The Centers for Disease Control (CDC) www.cdc.gov
  1-800-311-3435
• The Department of Health and Human Services
  www.hhs.gov 1-877-696-6775
• The Deployment Health Clinical Center
  www.deploymenthealth.mil 202-782-6563
• The Navy Environmental Health Center
  www.nehc.med.navy.mil/hp 757-953-0700
• The Air Force Institute of Operational Health
  (AFIOH) http//www.brooks.af.mil/afioh
  210-536-5454 DSN 240-5454 1888-232-ESOH (3764)
• The National Institutes of Health
  http//www.nih.gov 301-496-4000

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Summary Review

• AR 600-63, Army Health Promotion, defines health
  promotion and prescribes policy,
  responsibilities, and procedures for Army health
  promotion programs.
• Five functional areas are critical to ensure the
  success and effectiveness of health promotion
  programs health education/health promotion
  process, behavioral health interventions,
  physical, spiritual, and environmental and social
  programs
• The CHPC serves as the framework and structure
  for assessing, developing, implementing, and
  evaluating community health promotion programs.

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Summary Review

• Identify a range of disciplines that may be able
  to influence the factors that are producing an
  oral health problem
• Know how to identify the major stakeholders in a
  community, and existing partnerships/networks

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Summary Review

• Army Health Promotion
• Health education/ health promotion process
• Behavioral health
• Physical programs
• Spiritual programs
• Environmental/ social programs

Well Being
Health
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• QUESTIONS???

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Materials Developed by

• LTC Georgia dela Cruz, DMD, MPH
• LTC Wayne Combs, AN, PhD
• LTC Teresa I. Hall, AN, MS, RNC
• MAJ Nancy Saddler, AN,