Preventing Cavities in Preschoolers: Testing a Unique Service Delivery Model in American Indian Head Start Programs Principal Investigator: David Quissell, PhD. University of Colorado Anschutz Medical Center Colorado Native Oral Health Research (CNOHR)

Study Team Co-investigators Interventionists/COHS Judith Albino, PhD. Terry Batliner, DDS. Patty Braun, MD., MPH. Lucinda Bryant, PhD. Diana Cudeii, RDH. Carmen George, MS. Nicolas Johs, BA. David Quissell, PhD. Vong Smith, BA. Nikola Toledo, MSA. Others Stella Begay Helen Curley Nicole Garcia Tracy Goldtooth Rose Lee Lolita Spencer Nikola Toledo Cherise Watson

Partnerships Colorado School of Public Health University of Colorado School of Medicine University of Colorado School of Dentistry Colorado Native Oral Health Research Program Navajo Head Start Navajo Nation Human Research Review Board

Early Childhood Caries Dental caries in the primary teeth of children 0-6 years of age Most common chronic disease of childhood 5 times more common than asthma Infectious disease Largely preventable

Disparities 79% of AI/AN preschool children have caries experience 3 times greater than their non-Native counterparts Navajo children have highest rates among American Indians Mean number of dental surfaces = 19 IHS not able to meet need

World Health Organization Oral Health Promotion “the process of enabling people to increase control over, and to improve their health” “moving beyond a focus on individual behavior towards a wide range of social and environmental interventions” World Health Organization. 2010: http://www.who.int/topics/healthpromotion/en/

WHO Goals of Oral Health Promotion Increase awareness of oral disease, its severity and factors that contribute to it Reduce the number and intensity of risk factors for oral disease, e.g. reduce sugar intake Decrease barriers to oral health, e.g. increase access to tooth-healthy foods Increase access to prevention activities, e.g. fluoride varnish, dental visits Create healthy environments, e.g. fluoridated water

Conceptual Framework

Theoretical Framework Well-being of children depends primarily on the household production of health the physical and social setting in which the child lives, the customs of child care and child rearing regulated by the culture in which the setting is embedded, and the psychology of the child’s caretakers Harkness S. Super CM. The developmental niche: a theoretical framework for analyzing the household production of health. Soc Sci Med. Jan 1994; 38(2): 217-226.

Study Setting Navajo Head Start Centers Federal program-105 HS Centers Comprehensive child development program serving children ages 3-6 years and their families Community-based, child-focused program Overarching goal: increasing the social competence of young children in low-income families Head Start performance standards

Study Design Design: Phase 4 cluster randomized trial Unit of analysis: Head start classroom Intervention: fluoride varnish + parent oral health promotion education + classroom activities, delivered by Community Oral Health Specialists (COHS) Control: usual care Sample: 26 intervention classrooms + 26 usual care classrooms Timing: 2 years of intervention; 3 years of data collection

Intervention Structured for Academic Year Quarterly Fluoride Varnish Application Four Parent/Caregiver Events Five Child Activities

Community Oral Health Specialist Community Lay Health Worker Oral Health Specialist Child Educator Parent Educator Culturally Sensitive

Educational Strategy Engage the Learner Active Learning Small Groups informal conversations, storytelling Active Learning emphasize hands-on Small Groups encourage opportunities to interact Application of Knowledge practical applications Appropriate Communication culturally appropriate, ‘teach-back’ Reinforcement messages will be presented in a variety of formats, repeated

Curriculum Curriculum targets many influences on disease process Teeth Fermentable carbohydrates Bacteria Parent/caregiver Child Head Start teacher

Curriculum- Messages Improving oral health Tooth brushing twice daily Use fluoridated toothpaste Drink fluoridated water Fluoride varnish Help child brush Regular dental visits Reducing fermentable carbohydrates Reduce sugary/sticky foods Reduce frequent snacking More healthy snacks Reduce vertical transmission of S. Mutans Reduce oral sharing

Fluoride Varnish Application

Parent/Caregiver Events Kick–Off event with parents/caregivers and children Brings caregiver/child together Incorporates Head Start classroom into the intervention Engages the Head Start teacher into the process

Parent/Caregiver Events Begins with an educational presentation to give necessary knowledge to empower caregivers to make change Move to small group stations Engaging Hands on Self goal setting Follow up contact to assess progress on goal

Brief Educational Presentation Baby Teeth are Important for: SMILING! SPEAKING and SINGING! HOLDING SPACE FOR PERMANENT TEETH! EATING!

Small Group Stations

Caregiver Goal Setting Tool

Child Specific Sessions Builds on primary concepts Tooth function Tooth brushing Healthy eating Fluoride Dental visits Short, fun activities Coloring Sorting games Role playing Matching games

Summary Early childhood caries affects many Navajo children and is preventable Innovative use of Community Oral Health Specialists Directed toward the household production of health Head Start classrooms Theory-based curriculum

This research is supported by funding from the National Institute of Dental and Craniofacial Research agreement #1U54DE019259-01.

Thank you! Ahéhee!