Partnering with Community Health Centers to prevent ECCAbstractThe national public health agenda, as stated in Healthy People 2010. includes the goal to reduce theprevalence 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) hasbeen limited, especially among the children most vulnerable to ECC, so that prevalence of the disease remainsunacceptably high. However, recent efforts to address the problem of ECC in the medical care setting havebeen successful suggesting that this is a fruitful direction to pursue. Considering that about 95% of Americanchildren under age 6 attend regular well-child visits, pediatricians are potential allies to reduce risk for thedisease. Accordingly, the American Academy of Pediatrics has adopted a policy supporting pediatricians' useof caries risk assessment and referral to a dental home.Recent research has documented two efficacious strategies for reducing ECC incidence. First, there iscompelling evidence from several randomized controlled trials that fluoride varnish (FV) significantly reducesthe incidence of ECC. Given this, and because fluoride varnish applications are safe, cheap and easy toadminister even in non-dental settings, fluoride varnish applications should play a key role in the prevention ofECC. Second, our group recently found that training of pediatric clinicians to provide patient centeredcounseling (PCC) to reduce ECC risk factors (a counseling approach designed to enhance clinician and patientself-efficacy regarding behavioral change) resulted in a greater than 40% reduction in ECC incidence over 2years among young White, African American, Asian and Latino children. However, the efficacy of this approachhas not been tested in a randomized clinical trial. Furthermore, although prior studies have shown thatmultifaceted interventions including strategies to improve adherence to recommended health behaviors arelikely to be the most successful in both changing individual and health care provider behavior, this has notbeen comprehensively evaluated in the context of ECC prevention.Importantly, prior efforts did not evaluate the factors necessary for widespread implementation anddissemination of such strategies, including FV application and PCC in relevant settings. However, suchknowledge is urgently needed to widely disseminate efficacious interventions to children nationwide in thefuture.We hypothesize that patient centered counseling by pediatric clinicians during well-child visits will beeffective in reducing the incidence of ECC in children aged 1 to 3 years over and above any reduction in ECCincidence achieved by regular fluoride varnish applications. To test this hypothesis, we propose a clusterrandomized 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 HealthCenters (CHCs) in three states (Massachusetts, Maryland and Ohio), which will be randomized to either theintervention 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 pediatricclinicians to administer fluoride varnish and patient centered counseling vs. fluoride varnish alone to reduce the2-year incidence of ECC among one-year old children, to improve oral health related quality of life in thesechildren, to increase clinician knowledge about ECC, to increase clinician provision of fluoride varnish andcounseling to reduce ECC, and to reduce children's exposure to ECC risk factors. As a secondary aim, we willalso collect data on the prevalence of ECC among children 3 years old at study baseline, in order to have acomparison group to estimate the overall effectiveness of the multifaceted intervention (i.e., including the effectof the fluoride varnish application) in reducing ECC. Furthermore, we will identify and address the barriers toand 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 projectnarrative. The project Co-Pi Dr. Paul Geltman will take on the project-specific community liaisonresponsibility. His long-term community engagement experience, and his many years of directly serving theneeds of communities by his work in community health centers, make him ideally suited for that role. He willalso work closely with project personnel in Ohio and Maryland to ensure that community partners at thoseproject performance sites are fully engaged in the research.This proposed study uses an innovative approach to target vulnerable populations of young children thatare disproportionately affected by early childhood caries with an intervention of proven efficacy. Theknowledge garnered from the proposed project will have major public health implications because of itsadditional emphasis on identifying and addressing the factors that can both inhibit and facilitate futurewidespread implementation and dissemination to children nationwide.
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