Partnering with Community Health Centers to Prevent ECC

与社区卫生中心合作预防ECC 摘要 《2010年健康人》中所述的国家公共卫生议程。包括目标是减少 将儿童乳牙龋齿患病率降至11%或以下(目标21-1a)。不幸的是， 对预防幼儿龋齿(ECC)所需的饮食和卫生行为改变的认识 特别是在最容易感染ECC的儿童中，这种疾病的流行率仍然很低 高得令人无法接受。然而，最近在医疗保健环境中解决ECC问题的努力已经 取得了成功，这表明这是一个富有成效的方向。考虑到大约95%的美国人 6岁以下的儿童定期去看健康儿童，儿科医生是降低儿童患病风险的潜在盟友 疾病。因此，美国儿科学会通过了一项政策，支持儿科医生使用 进行龋齿风险评估并转诊至牙科之家。 最近的研究记录了两种有效的减少ECC发生率的策略。首先，有 来自几个随机对照试验的令人信服的证据表明，含氟清漆(FV)显著减少了 ECC的发生率。考虑到这一点，并且因为氟化物清漆应用是安全、廉价和容易的 即使在非牙科环境中，使用含氟清漆也应在预防牙病方面发挥关键作用 ECC。其次，我们小组最近发现，对儿科临床医生的培训提供以患者为中心 咨询(PCC)以降低ECC风险因素(一种旨在提高临床医生和患者素质的咨询方法 关于行为改变的自我效能感)导致ECC发生率比 在年轻的白人、非裔美国人、亚裔和拉丁裔儿童中，这一年的支持率很高。然而，这种方法的有效性 尚未在随机临床试验中进行测试。此外，尽管之前的研究表明， 多方面的干预措施，包括改善对推荐健康行为的遵守情况的战略 这可能是在改变个人和医疗保健提供者行为方面最成功的，但并没有 在预防ECC方面进行了全面评价。 重要的是，先前的努力没有评估广泛执行所需的因素， 传播这类战略，包括在相关环境中推广FV应用和PCC。然而，这样的 迫切需要知识来向全国儿童广泛传播有效的干预措施 未来。 我们假设，在健康儿童就诊期间，儿科临床医生以患者为中心的咨询将是 有效降低1至3岁以上儿童的ECC发生率 通过常规的氟化物清漆涂抹达到的发病率。为了检验这一假设，我们提出了一个集群 随机社区干预研究。我们将培训儿科临床医生(医生和护士) 应用氟化物涂膜和以病人为中心的咨询降低ECC危险因素(干预组) 或仅涂氟漆(对照组)。这项研究将在八个社区健康杂志上进行 三个州(马萨诸塞州、马里兰州和俄亥俄州)的中心(CHC)，这些中心将被随机分配到 干预组或对照组。这些社区健康中心共同服务于一系列贫穷的白人、非裔美国人、 加勒比移民和拉丁裔儿童，这是最容易受到ECC影响的群体。 因此，我们建议的研究将评估儿科培训计划的有效性和有效性。 临床医生使用氟化物涂膜和以患者为中心的咨询与单独使用氟化物涂膜相比，以减少 一岁儿童中两年的ECC发病率，以改善这些儿童与口腔健康相关的生活质量 儿童，增加临床医生对ECC的知识，增加临床医生提供的氟化物清漆和 咨询，以减少ECC，并减少儿童对ECC危险因素的暴露。作为次要目标，我们将 也收集研究基线时3岁儿童中ECC患病率的数据，以便有一个 比较组评估多方面干预的总体有效性(即，包括效果 使用含氟清漆)可降低ECC。此外，我们将确定并解决以下障碍 以及在干预和控制地点传播和实施计划的促进者。 这个项目是在与社区密切合作的情况下开发的，详见项目 叙事性。项目合作伙伴Paul Geltman博士将负责项目特定社区的联络工作 责任。他长期的社区参与经验，以及他多年来直接为 他在社区卫生中心的工作满足了社区的需求，使他非常适合这一角色。他会的 还与俄亥俄州和马里兰州的项目人员密切合作，确保那些 项目履约现场都在全力投入研究。 这项拟议的研究使用了一种创新的方法来瞄准易受伤害的幼儿群体， 儿童早期龋齿的影响是不成比例的，干预措施已被证明有效。这个 从拟议项目中获得的知识将对公共卫生产生重大影响，因为它 进一步强调确定和解决既能抑制又能促进未来的因素 在全国范围内广泛实施和向儿童传播。

Partnering with Community Health Centers to prevent ECC Abstract The national public health agenda, as stated in Healthy People 2010. includes the goal to reduce the prevalence of children with dental caries in their primary teeth to 11% or less (goal 21-1 a). Unfortunately, uptake of the dietary and hygiene behavioral changes needed to prevent early childhood caries (ECC) has been limited, especially among the children most vulnerable to ECC, so that prevalence of the disease remains unacceptably high. However, recent efforts to address the problem of ECC in the medical care setting have been successful suggesting that this is a fruitful direction to pursue. Considering that about 95% of American children under age 6 attend regular well-child visits, pediatricians are potential allies to reduce risk for the disease. Accordingly, the American Academy of Pediatrics has adopted a policy supporting pediatricians' use of caries risk assessment and referral to a dental home. Recent research has documented two efficacious strategies for reducing ECC incidence. First, there is compelling evidence from several randomized controlled trials that fluoride varnish (FV) significantly reduces the incidence of ECC. Given this, and because fluoride varnish applications are safe, cheap and easy to administer even in non-dental settings, fluoride varnish applications should play a key role in the prevention of ECC. Second, our group recently found that training of pediatric clinicians to provide patient centered counseling (PCC) to reduce ECC risk factors (a counseling approach designed to enhance clinician and patient self-efficacy regarding behavioral change) resulted in a greater than 40% reduction in ECC incidence over 2 years among young White, African American, Asian and Latino children. However, the efficacy of this approach has not been tested in a randomized clinical trial. Furthermore, although prior studies have shown that multifaceted interventions including strategies to improve adherence to recommended health behaviors are likely to be the most successful in both changing individual and health care provider behavior, this has not been comprehensively evaluated in the context of ECC prevention. Importantly, prior efforts did not evaluate the factors necessary for widespread implementation and dissemination of such strategies, including FV application and PCC in relevant settings. However, such knowledge is urgently needed to widely disseminate efficacious interventions to children nationwide in the future. We hypothesize that patient centered counseling by pediatric clinicians during well-child visits will be effective in reducing the incidence of ECC in children aged 1 to 3 years over and above any reduction in ECC incidence achieved by regular fluoride varnish applications. To test this hypothesis, we propose a cluster randomized community-based intervention study. We will train pediatric clinicians (both physicians and nurses) to apply fluoride varnish and to use patient centered counseling to reduce ECC risk factors (intervention group) or only to apply fluoride varnish (control group). The study will be conducted in eight Community Health Centers (CHCs) in three states (Massachusetts, Maryland and Ohio), which will be randomized to either the intervention or control groups. These CHCs together serve a range of poor White, African American, Caribbean immigrant and Latino children, groups which are most vulnerable to ECC. Our proposed research will therefore evaluate the efficacy and effectiveness of a training program for pediatric clinicians to administer fluoride varnish and patient centered counseling vs. fluoride varnish alone to reduce the 2-year incidence of ECC among one-year old children, to improve oral health related quality of life in these children, to increase clinician knowledge about ECC, to increase clinician provision of fluoride varnish and counseling to reduce ECC, and to reduce children's exposure to ECC risk factors. As a secondary aim, we will also collect data on the prevalence of ECC among children 3 years old at study baseline, in order to have a comparison group to estimate the overall effectiveness of the multifaceted intervention (i.e., including the effect of the fluoride varnish application) in reducing ECC. Furthermore, we will identify and address the barriers to and facilitators of program dissemination and implementation in both intervention and control sites. This project was developed in close collaboration with the community, as detailed in the project narrative. The project Co-Pi Dr. Paul Geltman will take on the project-specific community liaison responsibility. His long-term community engagement experience, and his many years of directly serving the needs of communities by his work in community health centers, make him ideally suited for that role. He will also work closely with project personnel in Ohio and Maryland to ensure that community partners at those project performance sites are fully engaged in the research. This proposed study uses an innovative approach to target vulnerable populations of young children that are disproportionately affected by early childhood caries with an intervention of proven efficacy. The knowledge garnered from the proposed project will have major public health implications because of its additional emphasis on identifying and addressing the factors that can both inhibit and facilitate future widespread implementation and dissemination to children nationwide.