Challenging Dogma - Fall 2008

Thursday, December 18, 2008

First 5 Education Training Initiative: Preaching to the Choir – Jessica Kissen

Oral hygiene is very important to children for various reasons. “Oral health affects people physically and psychologically and influences how they grow, enjoy life, look, speak, chew, taste food and socialize, as well as their feelings of social well-being.” (1) Children especially can be affected by bad oral hygiene. Dental caries, or tooth decay, can affect a child adversely. Children can experience severe “pain, discomfort, disfigurement, acute and chronic infections, and eating and sleep disruption.” (2) Dental problems in childhood could result in health problems in adulthood and/or could be signs of serious illness. (3) Unfortunately, across the world, maintaining good oral health is a big problem
Dental caries are an epidemic in the United States, although many in the United States don’t acknowledge it. According to research, many call the prevalence of dental caries a “silent epidemic.” This is due mostly because tooth ailments, although widespread, are not deadly and usually will just cause pain and discomfort that people can deal with until it is too late. (4) Unfortunately, it is more prevalent than people realize. Between the ages of 2 and 11, 42% of these children have dental caries. (5) What is worse is that Black and Hispanic people who live in poverty have the largest disparity of tooth decay. (6) But recently, because of an increased awareness to this epidemic, the United States has started to take notice and recognize oral health as something to focus on and has started to create different initiatives and interventions to help combat this growing epidemic.
In a study done in 2000, which was designed to assess a pediatrician’s knowledge of oral health and hygiene, the results show that pediatricians need more training in this area. (7) Stemming from this important study, a recent initiative was established called The First 5 Education Training Initiative; this intervention was piloted in California in February 2004. (8) The goals of this initiative is to educate and train dentists, medical professionals and early childhood educators about new scientific procedures and practices that can be used to promote oral health in children in their very early childhood (0 to 5 years). This intervention plans on eliminating the epidemic from the inside out. By educating the educators, this initiative is believed to provide more dental health care to children and better dental health care for children.
Unfortunately, this is not the case. This is obviously a very flawed intervention that doesn’t address the core problems with dental care and oral health. Although the study mentioned above recommends that pediatricians be educated in dental procedures and technology, this intervention does not address key elements to dental care. First 5 Initiatives do not address problems with the Medicaid Dental Care system. Although every single child who is enrolled in Medicaid has the right to dental services, only about 18 percent of these children have even come in for a check up. (9) Since the service is provided, why is there so small a number of children actually going to the dentist regularly? The other flaw deals with the target. Are we educating the right people with this program? Should we be educating the professionals or parents, teachers, and care-givers? The general public does not realize the severity of this epidemic, but professionals do. Why are we trying to educate people who already know that bad oral health is a major problem? The problem that might be hardest to combat is the social norms about dental care and oral health. Dental care is strongly viewed as an elective procedure for those who can afford it. Most people don’t believe the oral hygiene is very important. This program does not address how to make a change in the social norms about oral health. The program is ending its four year agenda in December 2008, and reports already show that it has been a failure. Failure to address the real problem with dental care and oral health made this initiative a waste of 7 million dollars.

First 5 Initiative Does Not Address How to Pay for Dental Procedures
Unfortunately, confirmed by the low percentage of Medicaid beneficiaries going to the dentist regularly, Medicaid’s plan does not seem to be attracting parents to send their children for regular check ups. “Medicaid programs face a myriad of difficulties, from low levels of participation by dentists to difficulties in teaching beneficiaries how to negotiate the dental care system.” (9) First 5 Initiatives tried to address the low participation through dentists. The program’s goal is to educate dental and medical professionals about the importance of dental care and oral health, and eventually these dentists and medical professionals will take Medicaid patients more often. Unfortunately, this could never be the case.
It has already been established that dental care for children is crucial to their overall health, but having a dental procedure takes time and money, and not many dentists or medical professionals are working for Medicaid. When a family has dental coverage, the dentist will be alert to the dental problems in the family and he will be reimbursed by that family’s dental insurance plan. Research shows that families who are in a higher socio-economic status (SES) go to the dentist regularly compared to mid to lower SES. (10) What does that tell us? People who are in the low SES range usually have Medicaid as their insurance. Medicaid families also have the State Children’s Health Insurance Plan, SCHIP, for their children, which is insurance coverage for mothers and their children. (11) SCHIP’s dental coverage is controlled on a state by state basis. There are still out-of-pocket fees, and other costs that apply to the program. As with many low-income families these fees may deter a mother from taking her child to the dentist. Not only are their fewer dentists that accept Medicaid and SCHIP, there are other constraints such as “inflexible work hours [and] distances to providers.” (10) These barriers do not help with dental care in children. And as the children age, these barriers don’t get any easier. Just because more professionals know about the problem, doesn’t mean that people are actually getting help. In conclusion, just by educating professionals about oral health does not help with payment and improvement in oral health.
First 5 Initiatives Does Not Target the Right People
The First 5 Initiative is a great plan addressing problems with knowledge about oral health in a professional community, but this professional community already knows about the dangers of dental caries and the need for regular visits to the dentist. The training that is instituted by this program is not even hands on. There are no patients on which they are performing procedures and check ups on. Many of the training sessions are even online through webcasting. How does this support a community of people who need to get dental care?
So who really needs the education? In an older study done in Romania that showed although many mothers knew about the dangers of poor oral hygiene, there was still a prevalence of tooth decay in many children. “On one hand, most of the mothers knew about the negative effect of sweets and candy; nevertheless, the consumption of various sugary foods was relatively frequent.”(12) This shows that although most mothers understand that some foods may cause a problem, they would rarely do anything about it. Translating this to First 5, shouldn’t we be training mothers to be more careful about what they feed their children? First 5 will do a great job educating professionals so that when a mother does bring a child in for a dental procedure or check up, the dentist will be able to talk to the mother. But, as we have discussed, many mothers don’t even take their children to the dentist. It is a waste of valuable training time.
When we look at this intervention in the perspective of a model, First 5 is trying to increase the amount of children going to the dentist from the inside out; meaning that the outcome we want to have is an increase in the number of children that get regular dental check ups. The exposure that we are using is educating professionals. Where is the link between professionals and children? Early educators are targeted by First 5. Unfortunately, this program targets children between the ages of 0 and 5 and this is before children have a chance to go to kindergarten. There is a missing link between the education of professionals and getting children to get dental care.
First 5 Ignores the Social Norms about Dental Care in the Community
Is dental care viewed as an essential and crucial part to a child’s health? Aside from the hassle and the money it takes to get a child to go to the dentist, do parents feel that it is so important that their children receive dental care? “Some parents mistakenly believe that younger children do not need to visit the dentist because the young children’s teeth are not permanent.”(10) Overall, the public doesn’t see dental care as very important to children who don’t have permanent teeth. Dental care seems to be put on a shelf until the children grow up. The barriers for dental insurance only get worse as children become older. Unfortunately, this can have some major consequences. What is the worst part about it is the fact that dental problems are easily preventable and treatable if the problem is diagnosed earlier. (13) This creates a rift between social norms and the consequence of not having dental care.
The questions to answer are how are any of the First 5 initiatives addressing the fact that people do not think dental care is important. This intervention fails to address the fact that the general public believes that dental care is a luxury. Mostly it is because parents do not realize that tooth decay is a real problem which is very preventable. In a report done by the Dental Health Foundation, the public opinion about “tooth decay [is that it] is a natural and minor occurrence that deserves little attention or dollars.”(14) Some parents can consider children caries as a minor inconvenience since they think that children’s teeth are temporary and the problem will go away when they have permanent teeth. (10)
Since dental care seems relatively unimportant to some people, people who can’t afford to take their children to the dentist for a regular check up will chose to avoid it. Having a co-pay or even gas on the trip may be more costly. In an important study published in the Journal of Community Dentistry and Oral Epidemiology, the author states that there is a need for educating mothers of a preschool age children about the importance of brushing teeth because mothers had no interest and no information about teaching their children how or why to brush their teeth daily. (15) Mothers had no interest to teach and monitor their children’s brushing habits because dental health isn’t as important to them as physical health. As stated above, evidence shows that it is just as important.
In conclusion, the First 5 was a complete disaster. It had the wrong target, the wrong approach, and the wrong idea. Educating people who were already educated was a waste of 7 million dollars. After looking at the data (16) we can even see that this was a failure. This pilot program did nothing but help us understand where First 5 went wrong. Although, from this intervention we will be able to create a better more effective initiative that targets the right people and puts money in the right places.

Learning from the First 5 Mistakes: First 5, Part 2 – Jessica Kissen

The First 5 Initiative piloted in California in 2004 didn’t work for many reasons. The initiative did not address key problems in dental health care delivery, coverage, and ignored the norms about dental health care. From the failure of First 5 we can learn from the mistakes and devise a new plan that has more potential to work because this new initiative focuses more on areas in health behavior that target the community and people to change attitudes and behaviors towards dental health. This plan is an extension of the First 5 Initiative and combats all the flaws that this initiative had.
The First 5 Free Dental Plan
The first problem to be addressed with First 5 deals with money. The First 5 initiative does not address how to pay for dental procedures. Not many people have dental insurance and dental procedures can be very expensive. As we have seen from previous research, much of the lower Socio-Economic Status population does not go to the dentist regularly. The government has tried to combat this by including some dental coverage in Medicaid and SCHIP. Unfortunately, this has not been working because even though there is a plan, the costs and premiums are still too high. In the First 5 Part 2 Initiative, these kinds of barriers will be eliminated with the First 5 Free Dental Plan. The First 5 Free Dental Plan (F5Plan) will be a government sponsored nationwide dental insurance plan. Families must apply for the plan and applicants will be chosen on the basis of their SES status and adherence to the First 5 Motherhood Training Program (to be discussed later). All applicants must have either Medicaid or SCHIP. They must also apply within the first year of the birth of their child. After enrolling in the program, the child will have bi-annual check-ups with dentists that are provided by the program. Dentists who are enrolled in the program will get subsidized for the check ups and can apply for an extra tax cut for providing more expensive procedures. This plan is based on a Political Economic model. (17) By addressing the monetary barriers that are faced by the mothers of the children, the mother will be more inclined to have dental coverage for their child. This will be done in conjunction with a plan that will educate the mother about the importance of oral health and the affordability of the F5Plan, called the First 5 Motherhood Training Program.
The First 5 Motherhood Training Program
Ideas about education are very important when it comes to dental health. Many people don’t understand the importance of oral health and the risks of poor oral hygiene, especially in children. In First 5, education is strongly emphasized in the professional community. Although the idea about education is the right way to go, medical professionals are already educated in the benefits of oral health. Parents don’t understand the importance of dental health for their children, especially at an early age. In Part 2, education will be geared towards the mothers of the children. Prenatal care is given to all expectant mothers enrolled in Medicaid and SCHIP. Part 2 will be included in this prenatal care and postnatal care.
In Part 2, there will be three training sessions during the last term of the mothers’ pregnancy. They will be free and will last between one to one and half hours. These training sessions will be designed specifically to educate mothers about the prevalence of poor oral hygiene, the severity of the problem, the consequences of poor dental care, and also about affordable dental care plans and the F5Plan. These sessions will be led by trained professionals, such as dentists and nurses. They will be able to answer questions that the mothers might have and also will provide brochures with even more information. If the mother attends all three sessions during the last term of her pregnancy, the mother will get a free dental exam and also be eligible for the Five Year Free Dental Program. Not only does this provide information to the mother about the oral health of their soon-to-be-born child, but it also gives the mother incentive to complete the program.
This program builds on the idea that most people don’t understand the health risks of having poor oral hygiene. As previous research has shown, much of the general population doesn’t understand the severity and importance of dental health. (18) The Health Behavior Model is one of the best ways to target these mothers with this program. (19) A mother sometimes doesn’t think that their child is susceptible to bad oral health. By showing that every child is at risk for dental caries and tooth decay, the mother will realize that their child is susceptible. The next step would be to help the mother understand that risks of poor oral hygiene. It can affect the child adversely and can damage their teeth and health for the rest of the child’s life. The mother can then learn about how easy it is to obtain dental insurance and get dental care for their child. This increases the self-efficacy of the mother because she now believes that she will be able to afford a dental plan. An increase in enrollment in dental insurance plans may spark more community involvement and a change in the social norms about dental coverage and care. The First 5 Community Incentive Program will help to further this change.
The First 5 Community Incentive Program
The next, and possibly the most important missing part of the First 5, is addressing the social norms about dental care. Although the First 5 Motherhood Training Program helps an individual understand the consequences and need for oral hygiene, the general population doesn’t understand the severity. This Community Incentive Program will be based in lower SES communities and is state-by-state sponsored. Here, the target is families in these communities and is less based on the oral hygiene of children, but more based of basic oral hygiene for everyone in that community. The idea behind this is to change the ideas about dental care to the parents of the children so that they will continue having dental insurance and coverage throughout the child’s life. Each state must sponsor a community education program that relates to teaching about dental health along with providing some form of dental services. Because this is a statewide program, every state may sponsor as much or as little as they would like, and can sponsor any program they see as best for the community. But the incentive part if the most important. At the end of each year there will be an assessment done by the government on the overall success of programs done in each state. The most successfully implemented plans and projects will be rewarded with a very large subsidy. Seventy percent of the subsidy must be used to expand the project to the next year and 30% can be used to the state’s discretion. Another perk of this program is that the most successful plans will be implemented nationwide in the third step of the First 5 Initiative’s overall plan.
This program builds on changing the community perspective on dental health care, coverage, and availability. Although plans may vary state to state, there are suggestions that can be rooted in the First 5 Community Incentive Program. There are so many ways a state may sponsor a program that can socially affect the community. Using the Social Networking Theory, a state can sponsor programs that target groups and then use those groups to outreach to other communities. (20) A state can sponsor dentists to come talk to a local community at a church and answer questions about dental care. Another way to help a community understand the importance of oral health is with the use of marketing and commercials. Community Access Television stations can be used to broadcast interviews with dentists. Dentists and nurses can be brought onto radios to answer questions in the community about dental insurance, coverage and care. Here, with the use of the communications theory, a state can fund the diffusion of information through public access. (21)
Overall, like most incentives, money is a huge issue. Without it, dentists don’t get paid, patients don’t get the treatment, children will have poor oral hygiene, and communities will still see oral health as something that isn’t important. By starting with this issue, the First 5 Initiative can build further onto other issues that deal with education and community involvement. This initiative has the potential to be very important and very beneficial to helping children get the dental care they need and helping parents understand the important of oral health.

1. Locker D. Concepts of oral health, disease and the quality of life. In: Slade GD, editor. Measuring oral health and quality of life. Chapel Hill: University of North Carolina, Dental Ecology; 1997, pp. 11-23.
6. Watt, R., and A. Sheiham. "Inequalities in oral health: a review of the evidence and recommendations for action." BRITISH DENTAL JOURNAL 187 (1999): 6-12.
7. Lewis, Charlotte W., David C. Grossman, Peter K. Domoto, and Richard A. Deyo. "The Role of the Pediatrician in the Oral Health of Children: A National Survey." PEDIATRICS 106 (2000): 1-7.
9. Edelstein, Burton L. Crisis in Care: The Facts Behind Children’s Lack of Access to Medicaid Dental Care. United States of America. Department of Health and Human Services. National Center for Education in Maternal and Child Health. May 1998.
10. Vargas, Clemencia C., and Cynthia R. Ronzio. "Relationship Between Children’s Dental Needs and Dental Care Utilization: United States, 1988–1994." American Journal of Public Health 92, (2002): 1816-821.
12. Petersen, Poul Erik, Danila, Ioan and Samoila, Anca(1995)'Oral health behavior, knowledge, and attitudes of children, mothers, and schoolteachers in Romania in 1993',Acta Odontologica Scandinavica,53:6,363 — 368
13. Vargas, Clemencia M., Robert E. Isman, and James J. Crall. "Comparison of Children’s Medical and Dental Insurance Coverage by Sociodemographic Characteristics, United States, 1995." Journal of Public Health Dentistry 62 (2002): 38-44.
14. The Dental Health Foundation, CALIFORNIA WORKING FAMILIES POLICY SUMMIT, 18 Jan. 2007, 520 3rd Street, Suite 108 Oakland, CA 94607. POLICY RECOMMENDATIONS ON ORAL HEALTH. 1-4.
15. Blinkhorn, Anthony S. "Influence of social norms on toothbrushing behavior of preschool children." Community Dentistry and Oral Epidemiology 6 (1978): 222-26.
16. FIRST 5 CALIFORNIA, Oral Health Education and Training Project. Rep.No. BARBARA AVED ASSOCIATES. 1-137.
Singer M. AIDS and the health crisis of the U.S. urban poor: the perspective of critical medical anthropology. Soc Sci Med. 1994;39(7):931-948.
Vargas, Clemencia C., and Cynthia R. Ronzio. "Relationship Between Children’s Dental Needs and Dental Care Utilization: United States, 1988–1994." American Journal of Public Health 92, (2002): 1816-821.
Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q. 1984;11(1):1-47.
Pescosolido BA, Levt JA, eds. Social Networks and Health, 8th ed. Elsevier, Inc.; 2002.
Lasswell H. 1948. “The Structure and Function of Communication in Society.” In L. Bryson (Ed.), The Commnicatio of Ideas. New York: Harper & Row.

Labels: , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home