Poor oral health in low income communities is a wicked problem that causes many burdens on children and adults alike. There is a wide disparity in untreated tooth decay and school absenteeism. The CDC reports that one in three children ages 2 through 5 who had family incomes below $10,000, experienced at least one decayed tooth that had not been treated. In contrast, only one in ten preschool children whose family incomes were $35,000 or higher had untreated caries. The CDC shows this disparity rate is true for teenagers and adults as well. Oral health is important because untreated caries can lead to problems with eating, speaking, and attending to learning in children and work attendance in adults. In addition, untreated caries and gum disease will lead to tooth loss. CDC survey data shows that low-income adults suffer more severe tooth loss than their wealthier counterparts. For example, adults in families earning less than $15,000 per year were more than 2-1/2 times as likely to have lost six or more teeth from decay or gum disease as adults in families earning $35,000 or more. Frequently cited barriers to improving the dental health disparities and achieving these target outcomes include cost, unwillingness of dentists to participate in Medicaid, low Medicaid reimbursement rates, oral health literacy concerns, and a lack of transportation. These barriers contribute to a lack of access for dental care in low income neighborhoods. Beyond the public health consequences of poor oral health are outcomes that affect families and communities in the financial, educational and workforce sectors. These outcomes can prevent families from improving their low income status.
Wicked Problem Description:
Poor oral health afflicts many low-income and other vulnerable populations. Poor oral health can lead to unnecessary tooth decay, periodontal disease, plaque buildup, pain and even the quiet and deadly advancement of oral cancer. It also leads to unnecessary and expensive visits to the Emergency Department to treat pain of tooth decay and periodontal disease but not the causal conditions. Finding ways to improve oral health in low-income communities is essential to good health and helping individuals move from poverty to middle class status. It requires a collaborative effort of a diverse array of health care workers.
To address the vast oral health disparities that exist for low income and minority families, the dental/healthcare neighborhood program seeks to create a community wide comprehensive oral health network in a low income and minority neighborhood to increase access to oral health education and oral health services. The oral health program will:
- Provide Community Needs Assessments – The urban neighborhood environmental scan provided a needs assessment specific to the West Atlanta neighborhoods. The needs assessment will inform the team’s understanding of which oral health services are most in need and how to best offer these services. Urban setting (completed); Rural setting (in process).
- Increase the number of healthcare professionals in low income areas trained to provide basic oral health care/cancer screening in low income communities. We will train primary care registered nurses, nurse practitioner, and nurse practitioner students to provide basic oral examinations, cancer screening and how to administer fluoride rinses.
- Improving community knowledge about oral care issues.
- Increase the dental workforce by allowing dental hygienists to perform preventive dental care via indirect supervision.
- Increase Capacity of Low Cost Oral HealthCare: 1) The HEALing Community Center at Neighborhood Union is located in the targeted neighborhood and has the capacity to provide 10,000 visits per year. It is also located in the same building as a Fulton County Women, Infants, and Children (WIC) office. 2) The HEALing Community Center will be opening a school based health program at a school in our target area to provide care to students, their families and their teachers. This project will train community health workers, nurses and nurse practitioners who work in the neighborhood schools to provide basic dental services and exams.
- Needs Assessments
- Dental Community Needs Assessment Performed by Rollins School of Public Health.
- Dental Provider Needs Assessment Performed.
- Established Advisory Committee
- Dental Hygiene Bill Passed – Increased Access for under-resourced children and adults.
- Working with Georgia Dental Hygiene Association and Georgia Dental Association to create an for Implementation tool kit.
- Dental Access
- Establishing another clinic (Neighborhood Union) to provide oral health services.
- Establishing another school based health clinic with oral health services.
- 2 publications –
- Moore CE, Reznik DA, Conboy L, Giwa J, Aslam F,5, Bussenius H, Aidman C, and Warren RC. Achieving Equity in Oral Health: A Data-driven Approach for Informing Policy Changes. Journal of Community Medicine & Health Education. J Community Med Health Educ 2017.
- Bussenius H, Moore CE, Reznik DA. Change in Culture: Building A Culture of Oral Health Care. Journal for Nurse Practitioners. Accepted for publication.
- Oral Health Impact Profile selected to measure oral health related quality of life.
- Partnered with Dan Enger and Global Dialogues to capture, via StoryCorps, the individual stories of community members focused on oral health.
- 2 publications –
Anticipated Future Outcomes
- Developing Protocols for NP/Nurses; Assisting in the development of protocols for general supervision of dental hygienists; OH I CAN website and APP with registry development; Developing oral health protocols for primary care; Oral cavity cancer screening training for providers; Rural Setting Community Needs Assessment.
• Advocacy efforts focused on oral health issues 1-24 months
• Developing Protocols for NP/Nurses - 12 months
• Assisting in the development of protocols for dental hygienists (state level) if needed - 6 months
• Website development - 6 - 10 months
• Oral health protocols for primary care - 12 months
• Oral cavity cancer screening training for providers - 12 months
• OH I CAN App with Repository - 6 months
• Rural Setting Community Needs Assessment 4 - 6 months
• Evaluate new methods to screen for oral HPV infections - 6 months
• Develop protocols to monitor oral HPV infections 6 -12 months
• Implementation of Oral Health Program at Urban FQHC -2 months
• Development of Business Plan for oral health programs 6 - 12 months
• Obtain individual stories of community members in rural and urban settings 6-24 months
• Development of oral health program in rural setting 18 months
• Identify additional sites to expand the program 12-18 months
• Identify funding sources to assist with further development of program elements 1-24 months
• Dissemination of work 12-24 months
HEALing Community Center, Centers for Disease Control, Rural FQHC - Ellenton Farmworker Clinic, Global Dialogues, Emory Rollins School of Public Health, Morehouse Public Health Program, Emory School of Nursing, Georgia Dental Association, Georgia Dental Hygiene Association, Ben Massell Dental Clinic, Organization for Safety, Asepsis and Prevention (OSAP) in Dentistry, the NYU Atlanta-based AEGD residency program.
Proposed Evaluation Questions: The evaluation team lead by the CDC will work with the partners to refine or modify, if needed, the measures and metrics described in this program, and to finalize the evaluation questions, design, and data collection plan. The outcomes, measures, and metrics will be summarized in a logic model, along with the collaboration’s assumptions, resources, strategies, and activities.
Process Evaluation Methods: Once the evaluation design has been finalized, the development of the collective impact collaboration will be assessed through periodic observations of collaboration meetings, reviews of program documents with stakeholders, and surveys of collaboration partners. The interviews/focus groups will be guided by the principles of collective impact and best research on dental care and health care education services.
Outcome Evaluation Methods: In the case of patients who access care at one of the HEALing Community Center clinics, the Oral Health Impact Profile (OHIP-14, Slade 1997), which measures the oral health related quality of life before and after treatment. For health care providers we will conduct pre and posttest surveys to determine the efficacy of the teaching modality.
Data Processing and Analysis: A collaborative of Atlanta’s health institutions will work with the team for the collection of real-time data using a smartphone app and registry, data entry Qualitative data analysis techniques will be used to ensure that data summaries and interpretations are both valid and reliable. Quantitative data analysis techniques will be used to assess implementation and outcomes at various points and over the 3-year grant period.