Caries prevalence and patterns and their relationship to social class, infant feeding and oral hygiene in 4-5-year-old children in Amman, Jordan.

OBJECTIVES: To investigate the relationship between social class, infant feeding, oral hygiene, and prevalence and patterns of caries in 4-5-year-old Jordanian children. METHOD: Two-stage random sampling procedure was used to select children enrolled in kindergartens in Amman, Jordan. Clinical examinations were carried out by one examiner. Mothers completed questionnaires relating to social class, infant feeding and the oral hygiene habits of the children. RESULTS: Sixty-seven per cent of the children had caries; 30% had the more extensive pattern involving molars and incisors. When the significant variables were taken into account, age, social class, sleeping with the mother, use of comforter and confectionery at bed/night time were shown to be independent risk factors for caries experience. Bottle-feeding at nap/bed/night time was associated with caries in incisors and caries in incisors and/or canines. Never being breast-fed, being breast-fed for more than 18 months, being breast-fed at nap/bed/night time showed a negative association with caries confined to molars although this showed a positive association with the more extensive pattern of the disease. CONCLUSIONS: Education for mothers about appropriate breast and bottle-feeding practices should be considered in health promotion strategies.

Food and drink consumption, sociodemographic factors and dental caries in 4-5-year-old children in Amman, Jordan.

OBJECTIVE: To investigate the association between type of food and drink consumption, sociodemographic factors and prevalence and severity of caries in 4-5-year-old Jordanian children. METHOD: Two-stage random sampling procedure was used to select children enrolled in kindergartens in Amman. Clinical examinations were carried out by one examiner. Mothers completed a questionnaire relating to sociodemographic factors and food and drink consumption. RESULTS: Snack foods were consumed by a high percentage of children. Amongst the most popular 'high in NME sugar snacks', confectionery was reported to be regularly consumed by 76% and biscuits and cakes by 71% of them. More than 50% had carbonated drinks. Children from a lower social class, attending a kindergarten with lower tuition fees had more dessert, squashes and more teas with sugar. When all variables were considered, consumption of confectionery was independently associated with caries prevalence and consumption of teas with sugar was independently associated with caries severity. CONCLUSION: The types of foods and drinks consumed as snacks by young Jordanian children were similar to those of Western countries. In the absence of more widespread oral health promotion measures and in the presence of high prevalence and severity of caries,the oral health of Jordanian children is a matter of concern.

Caries in preschool children in Amman, Jordan and the relationship to socio-demographic factors.

OBJECTIVE: To determine the prevalence and severity of caries in children attending kindergartens in Amman and the relationship between caries experience and socio-demographic factors including age, social class based on the father's occupation, the level of mother's education and the fee level of the kindergarten attended. DESIGN: Cross sectional survey including a dental examination of the child and a questionnaire completed by the parents. SETTING: Kindergarten schools in Amman. PARTICIPANTS: 1,140 children including 569 4-year-olds and 571 5-year-olds. RESULTS: Prevalence of caries in 4 year olds was 62% and in 5 year olds it was 73%. The dmft values were 3.1 and 4.1 in 4 and 5 year olds respectively. Lower caries prevalence was recorded for children of families where the father had a non-manual occupation, those whose mothers had higher levels of educational attainment and for children attending kindergartens with higher tuition fees. CONCLUSION: Caries prevalence and severity in children attending kindergarten schools in Amman are similar to those seen in studies of children of the same age in Saudi Arabia and higher than those in children in westernised countries such as the UK. As in other countries, caries experience in young children in Amman is clearly related to social factors. Findings illustrate the need for effective oral health promotion accessible to all social groups in this middle eastern capital. Fee scale of the schools appears to be an effective measure to use in designing appropriate strategies.

The effect of parental monetary sanctions on the vaccination status of young children: an evaluation of welfare reform in Maryland.

OBJECTIVE: To determine whether financial sanctions to Aid to Families With Dependent Children (AFDC) recipients can be used to improve vaccination coverage of young children. DESIGN: Randomized controlled trial. SETTING: Six AFDC jurisdictions in Maryland. INTERVENTION: Recipients of AFDC were randomized to the experimental or control group of the Primary Prevention Initiative. Families in the experimental group were penalized financially for failing to verify that their children received preventive health care, including vaccinations; control families were not. PARTICIPANTS: Children aged 3 to 24 months from assigned families were randomly selected for the evaluation (911 in the experimental, 864 in the control, and 471 in the baseline groups). MAIN OUTCOME MEASURES: Up-to-date for age for diphtheria and tetanus toxoids and pertussis (DTP), polio, and measles-mumps-rubella (MMR) vaccines; missed opportunities to vaccinate; and number of visits per year. ANALYSIS: Comparisons among baseline and postimplementation years 1 and 2. RESULTS: Vaccination coverage of children was low. Less than 70% of children were up-to-date for age for polio and MMR vaccines; slightly more than 50% were up-to-date for DTP vaccine. Up-to-date rates differed little among baseline, experimental, and control groups. Over time, there was a decrease in missed opportunities, and more children made at least 1 well-child visit; however, neither improvement resulted in a change in vaccination status. CONCLUSIONS: The Primary Prevention Initiative did not contribute to an increase in vaccination coverage among these children. Minimal economic sanctions alone levied against parents should not be expected substantially to affect vaccination rates.

Changes in clinic vaccination coverage after institution of measurement and feedback in 4 states and 2 cities.

BACKGROUND: Since 1995, states and jurisdictions receiving federal immunization funds have been required to perform annual measurements of vaccination coverage in their public clinics, based on data from Georgia where clinic coverage increased after the institution of a measurement and feedback intervention. OBJECTIVE: To determine if clinic vaccination coverage improved in localities that used the Georgia intervention model. DESIGN: Retrospective examination of clinic vaccination coverage data. PARTICIPANTS: Children aged 19 to 35 months enrolled in clinics in localities that had applied the intervention for 4 years or longer. INTERVENTION: The Georgia intervention model: assessment of clinic vaccination coverage, feedback of the information to the clinic, incentives to clinics, and promotion of exchange of information among clinics (AFIX). MAIN OUTCOME MEASURE: Change in median clinic coverage rates, based on the primary (4-3-1) vaccine series, with comparison to results of the National Immunization Survey. RESULTS: Four states and 2 cities that had applied the AFIX intervention for 4 years or longer were identified. The number of clinic records reviewed annually was 4639 to 18000 in 73 to 116 clinics for states, and 714 to 5276 in 8 to 25 clinics for cities. Median clinic coverage rose in all localities: Missouri, 44% (1992) to 93% (1997); Louisiana, 61% (1992) to 83% (1997); Colorado, 55% (1993) to 75% (1997); Iowa, 71% (1994) to 89% (1997); Boston, Mass, 41% (1994) to 79% (1997); and Houston, Tex, 28% (1994) to 84% (1997). The increase in clinic coverage exceeded that of the general population in 5 localities and was identical in the sixth. The average annual coverage rise attributable to the intervention was +5 percentage points per year (Georgia, +6 per year). The average crude direct program cost was $49533 per locality per year. CONCLUSION: The Georgia intervention model (AFIX) can be reproduced elsewhere and is associated with improvements in clinic vaccination coverage.

Assessing immunization performance of private practitioners in Maine: impact of the assessment, feedback, incentives, and exchange strategy.

INTRODUCTION: A provider-based vaccination strategy that has strong supportive evidence of efficacy at raising immunization coverage level is known as Assessment, Feedback, Incentives, and Exchange. The Maine Immunization Program, and the Maine Chapter of the American Academy of Pediatrics collaborated on the implementation and evaluation of this strategy among private providers. METHODS: Between November 1994 and June 1996, the Maine Immunization Program conducted baseline immunization assessments of all private practices administering childhood vaccines to children 24 to 35 months of age. Coverage level assessments were conducted using the Clinic Assessment Software Application. Follow-up assessments were among the largest practices, delivering 80% of all vaccines. RESULTS: Of the 231 practices, 58 were pediatric and 149 were family practices. The median up-to-date vaccination coverages among all providers for 3 doses of diphtheria-tetanus-pertussis vaccine and 2 doses of oral polio vaccine, and 4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of oral polio vaccine, and 1 dose of measles-mumps-rubella vaccine at age 12 and 24 months were 90% and 78%, respectively, and did not vary by number of providers in a practice or by specialty. Urban practices had higher coverage than rural practices at 12 months (92% vs 88%). The median up-to-date coverage for 4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of oral polio vaccine, and 1 dose of measles-mumps-rubella vaccine at 24 months of age improved significantly among those practices assessed 1 year later (from 78% at baseline to 87% at the second assessment). On average, the assessments required 21/2 person-days of effort. CONCLUSIONS: We document the feasibility and impact of a public/private partnership to improve immunization delivery on a statewide basis. IMPLICATIONS: Other states should consider using public/private partnerships to conduct private practice assessments. More cost-effective methods of assessing immunization coverage levels in private practices are needed.

Information as intervention: how Georgia used vaccination coverage data to double public sector vaccination coverage in seven years.

All states are now required by federal law to measure immunization coverage in each public clinic in their jurisdiction once a year. This law is based on data suggesting a twofold increase of immunization coverage in public clinics in Georgia during a seven-year period when the state developed a system for measuring clinic coverage and using these data to stimulate immunization performance. Review of the history of the development of the Georgia system suggests that measurement alone is not sufficient to raise coverage, however. In Georgia, measurement was coupled with a vigorous program of feedback of coverage data, provision of incentives for good performance, and exchange of information among clinics. The Centers for Disease Control and Prevention (CDC) has summarized the Georgia system with the acronym AFIX--Assessment, Feedback, Incentives, eXchange of information--and recommends that all state immunization program managers test and adapt this methodology. The article comments on the development of the Georgia system and describes why CDC believes other states should adopt it.

Changes in dental caries prevalence of school children in Araraquara, SP, Brazil.

The aim of this study was to compare the prevalence of caries in 1989 and 1992 in 7-12 year old school children in Araraquara, SP, Brazil. Systematic random samples were drawn from school children enrolled in the urban public schools and the surveys were carried out by trained examiners using the DMFT index. The results showed that in all ages there was an increase in the percentage of children free of caries for the permanent dentition (from 29.0 per cent in 1989 to 40.6 per cent in 1992). A decrease in the percentage of children classified in the 1-3 DMFT index category (from 40.0 per cent in 1989 to 33.7 per cent in 1992) and a decrease in the percentage of those classified in the 4-6 DMFT index category (from 26.6 per cent to 22.5 per cent) was observed. A slight decrease in the prevalence of children classified in the 7 or more DMFT index category was also observed (from 4.4 per cent to 3.1 per cent). The results obtained suggest that continuing efforts should be made to reduce the percentage of children with experience of caries in order to achieve the WHO/FDI goals for the year 2000.

Effectiveness of computer-generated telephone messages in increasing clinic visits.

OBJECTIVE: To evaluate the effectiveness of computer-generated telephone reminder calls in increasing kept appointment rates in a public health setting. DESIGN: Randomized controlled trial. SETTING: Public health clinic, Georgia. PATIENTS: Five hundred seventeen clients with scheduled appointments during a 4-week period at immunization, women, infant, and children; well-child; or family-planning programs. INTERVENTION: A single computer-generated telephone reminder 1 day before each client's scheduled appointment. MAIN OUTCOME MEASURE: Rates of kept appointments. RESULTS: Of the 277 clients assigned to receive the intervention, 144 (52%) kept their appointments, compared with only 78 (32.5%) of 240 who were not assigned to receive a message (P < .05). Improvement in kept appointment rates associated with receiving the message was highest for the immunization-program (183% increase, P < .05), with increases of 64%, 53%, and 44% for the well-child; women, infant, and children; and family-planning programs, respectively. CONCLUSIONS: These results suggest a simple and effective method to increase kept appointment rates in a variety of public health programs.

CPITN: time and cost estimates for periodontal prevention and treatment procedures.

The aim of this study was to estimate the necessary time and cost for periodontal prevention and treatment in a working population from sugar and alcohol refineries in Araraquara, SP, Brazil. A stratified sample of 528 employees aged 18-64 from administrative, industrial and agricultural staffs was examined by one examiner, previously trained, according to the community periodontal index of treatment needs (CPITN). The time required for procedures and the cost was extrapolated to the total worker population. The results showed that the estimated time required for periodontal prevention/treatment was 4527 hours. Of this time, 1783 hours were required for oral hygiene instruction, 2531 for scaling, 151 for surgery and 62 for maintenance. The cost would be US $17,655 for hiring a dentist for 8 hours/day to provide oral hygiene instruction, scaling, surgery and maintenance. However, the cost would be US $9,028 for hiring a dentist for 4 hours/day to provide surgery and maintenance and a dental hygienist for 8 hours/day to provide scaling and oral hygiene instruction. Taking into account epidemiologic, technical and economic aspects, the decision relating to manpower should be this second option.

Periodontal conditions and treatment needs (CPITN) in a worker population in Araraquara, SP, Brazil.

This research was carried out to assess the periodontal conditions and treatment needs in a worker population at Sugar and Alcohol Refineries in Araraquara, SP, Brazil. A sample of 528 workers aged 18-64 years was examined by one examiner, previously trained, using the CPITN. The results showed that calculus was the most frequently observed periodontal condition in the age groups 18-19, 20-24, 25-29 and 30-34. In the age groups 35-44 and 45-64, the periodontal condition most frequently observed was shallow pockets. The analysis of the results showed that treating all conditions in all persons would demand an amount of care that could not be provided by any dental service. Therefore, the priority should be based on population strategy and primary prevention programmes to benefit the periodontal health of the majority of people.

A million dollar measles outbreak: epidemiology, risk factors, and a selective revaccination strategy.

Between February 8 and April 4, 1986, an outbreak of measles occurred in the State of Arkansas. A total of 489 suspected measles cases were reported from 53 counties; 86 schools statewide reported suspected measles cases. There were 284 cases confirmed in 18 counties; 23.6 percent among students in one university and 41.2 percent among students in kindergarten through 12th grade in 32 schools. An epidemiologic investigation was carried out to evaluate risk factors for vaccine failure and to assess the effectiveness of a selective revaccination strategy in the outbreak setting. A cohort study conducted at a junior high school showed that, compared with students vaccinated against measles at ages 15 months or older, those vaccinated at ages 12-14 months had a three-fold increased risk of measles (relative risk 3.2, 95 percent confidence interval 1.5, 6.9). For schools reporting measles, the Arkansas Department of Health and the Department of Education jointly required reimmunization of students vaccinated at ages younger than 15 months and the exclusion of students not vaccinated at ages 15 months or older until they were vaccinated or until 2 weeks after the last rash onset. To implement these recommendations, more than 100,000 doses of combined measles-mumps-rubella vaccine were distributed at a cost greater than $1 million.