Alana Casciello, MPHMichelle Henshaw, MPH, DDS

Northeast Center for Research to Evaluate and Eliminate Dental Disparities

Boston University Henry M. Goldman School of Dental MedicineDepartment of Health Policy and Health Services Research

NIDCR - U54 DE019275

• Oral health disparities as a public health

problem

• Northeast Center for Research to Evaluate

and Eliminate Dental Disparities

• Oral Health Advocates in Public Housing (aka Tooth Smart Healthy Start)

• Implementation challenges and solutions

Oral Health MattersOral health is important for overall health

Oral health impacts:The way we talkHow we look How we feel about ourselves How others view us How we manage and perform daily

tasks

Oral Health Problems in Children

Pain

Difficulty chewing

Sleeping problems

Trouble

concentrating

Missed school

Fatigue, irritability,

depression

Behavioral issues

Early tooth loss

Impaired speech

development

Reduced self-esteem

Reluctance to smile

or laugh

Link between Oral and Systemic Health

• Pre-term and low birth weight babies

• Heart disease

• Stroke

• Diabetes

• Osteoporosis

“Despite improvements in oral health status, profound disparities remain in some

population groups as classified by sex, income, age, and race/ethnicity. For some diseases and conditions, the magnitude of the differences in oral health status among

groups is striking.”

Oral Health in America: A Report of the Surgeon General. Rockville, MD: USDHHS, NIDCR, NIH, 2000.

Trends in Oral Health Status among Children

Among 2-5 year olds, the prevalence of dental caries in primary teeth significantly increased from approximately 24% to 28%.

For 2-11 year olds, the mean number of decayed and filled primary teeth has significantly increased.

3X as many children aged 6-11 (12%) from families with incomes below the federal poverty line have untreated tooth decay, compared with children from families with incomes above the poverty line (4%).

US, ’88-’94 and ’99-’04; CDC report using NHANES data, Dye, B. April 2007

Early Childhood Caries (ECC)

www.bu.edu/creedd

CREEDDCenter Co-PI’sRaul Garcia, DMD, and Michelle Henshaw, DDS, MPH

Major Projects and Co-PI’s

“Partnering with Community Health Centers to Prevent Early Childhood Caries”Judith Bernstein, PhD, and Paul Geltman, MD, MPH Boston University Schools of Medicine and Public HealthNorman Tinanoff, DDS, University of Maryland Dental School

“Oral Health Advocates in Public Housing” Michelle Henshaw, DDS, MPH, Boston University, and Belinda Borrelli, PhD, Brown University School of Medicine

Oral Health Disparities in Boston Public Housing

The annual household income of 57.9% of Boston families living in public housing is less than $20,000.

Of families with young children, 54% are Hispanic, 33% are Black, Non-Hispanic and 6.7% are White, Non-Hispanic

Public Housing Residents’ Perspectives on Oral Health

Residents have identified oral health as an issue:

Health questionnaire: “What personal health issues concern you the most?” (open ended)17% reported dental health

FISP Survey: “What health concerns do you currently have?” (close ended)

55% reported dental health2nd highest below safety/violence (58%)

Community EngagementFocus groups informed the research design -

especially the importance of peer interventionists and counseling sessions conducted inside the home

Community Committee for Health Promotion (CCHP) and Boston Housing Authority partners assisted with the identification of study personnel

CCHP sub-committee for review of recruitment materials and research instruments

CCHP chose “Tooth Smart Healthy Start” as the moniker for the study

Oral Health Advocates in Public Housing

Oral Health Advocates in Public Housing Does a behavioral intervention

(Motivational Interviewing), delivered by public housing residents (‘oral health advocates’) to their peers, reduce incidence of early childhood caries over a two-year period?

Oral Health Advocates in Public HousingStudy design:

Randomized* clinical trial

Primary outcome assessment: 2 year caries incidence

Intervention: Both Intervention and Control groups receive the

same written oral health education materials, quarterly oral health assessments and fluoride varnish applications, and referrals to dental providers

Intervention group receives quarterly MI counseling visits with an oral health advocate

Developments - Boston Developments - Brookline Developments - Cambridge

Alice Taylor Egmont Street Veterans Apartments 226 Norfolk StreetArchdale High Street Veterans Apartments Cambridgeport CommonsBromley Park/Heath Street Trustman Apartments Fairmount Street Cathedral Walnut Street Apartments Hingham StreetCharles Newtown Inman StreetCharlestown Jackson GardensCommonwealth Jackson StreetFairmount Jefferson ParkFaneuil Gardens Jefferson Park 202Franklin Field/Franklin Field Family John Corcoran ParkFranklin Hill Lincoln WayGallivan Boulevard Newtowne CourtLenox Street/Camden Street Putnam GardensMary Ellen McCormack River Howard HomesMaverick Landing Roosevelt TowersMission Main Valentine StreetOld Colony Washington ElmsOrchard Commons Washington StreetOrchard Gardens Willlow Street HomesOrient Heights Woodrow Wilson CourtWashington BeechWest BroadwayWhittier Street

Oral Health Advocates in Public Housing

Target: Enroll 1,860 caregivers and their children

between the ages of 0 and 5 years from 26 public housing developments

Progress to date: Enrolled 1,312 caregivers and a total of

1,675 children between the ages of 0 and 5 years from 26 public housing developments

Implementation ChallengesMost common concerns among

residentsSafety of fluoride varnishDivulging personal informationCompeting demands on time

Unreliable/unstable communication methods (e.g. disconnected phone numbers/limited calling plan)

2-year follow-up periodRecruitment and retention is resource

intensive

Effective Recruitment and Retention Strategies

On-site delivery of oral health preventative services and educational

materials

Hiring bilingual, former/current public housing residents

Incentives (e.g. gift cards, monthly raffle, educational supports)

Branding (e.g. logo, uniforms, business cards, recruitment flyer design)

Door-to-door recruitment is more effective than either targeted or mass

mailings or bulletin board postings

Conducting both evening and weekend door-to-door recruitment and

phone contact attempts

Effective Recruitment and Retention Strategies

Offering in flexible appointment schedule – morning, afternoon,

evening, and weekend

Participating in and hosting on-site outreach events (e.g. Bingo,

movie screening, health and wellness fairs)

Obtaining alternate contact information for study participants

Text messaging

Conducting confirmation calls for study appointments

Hand-delivering or mailing postcards for missed visits or

difficulties in phone communication

Mailing birthday cards for children

The Role of the Dental Health Advocate

To improve the oral health of infants and children by learning about oral development, oral disease, oral hygiene, fluoride, and nutrition

To educate parents and their children about the importance of oral health

To work in partnership with oral health professionals

To increase early detection and prompt treatment of oral health problems

To create an awareness of the availability and value of preventive heath-care services