Organizational Readiness to Implement System Changes in an Alaskan Tribal Dental Care Organization.

INTRODUCTION: Tribal health care systems are striving to implement internal changes to improve dental care access and delivery and reduce health inequities for American Indian and Alaska Native children. Within similar systems, organizational readiness to implement change has been associated with adoption of system-level changes and affected by organizational factors, including culture, resources, and structure. OBJECTIVES: The objectives of this study were to assess organizational readiness to implement changes related to delivery of evidence-based dental care within a tribal health care organization and determine workforce- and perceived work environment-related factors associated with readiness. METHODS: A 92-item questionnaire was completed online by 78 employees, including dental providers, dental assistants, and support staff (88% response rate). The questionnaire queried readiness for implementation (Organizational Readiness for Implementing Change), organizational context and resources, workforce issues, organizational functioning, and demographics. RESULTS: Average scores for the change commitment and change efficacy domains (readiness for implementation) were 3.93 (SD = .75) and 3.85 (SD = .80), respectively, where the maximum best score was 5. Perceived quality of management, a facet of organizational functioning, was the only significant predictor of readiness to implement change (B = .727, SE = .181, P < .0002) when all other variables were accounted for. CONCLUSION: Results suggest that when staff members (including dentists, dental therapists, hygienists, assistants, and support staff) from a tribal health care organization perceive management to be high quality, they are more supportive of organizational changes that promote evidence-based practices. Readiness-for-change scores indicate an organization capable of institutional adoption of new policies and procedures. In this case, use of more effective management strategies may be one of the changes most critical for enhancing institutional behaviors to improve population health and reduce health inequities. KNOWLEDGE TRANSFER STATEMENT: The results of this study can be used by clinicians and other leaders implementing changes within dental care organizations. To promote organizational readiness for change and, ultimately, more expedient and efficient adoption of system-level changes by stakeholders, consideration should be given to organizational functioning generally and quality of management practices specifically.

Evaluation of a parent-designed programme to support tooth brushing of infants and young children.

OBJECTIVES: This study developed and tested an intervention to help parents establish a routine of brushing their young children's teeth twice a day. METHODS: Community-based participatory research methods were used to engage parents in the design of the intervention to maximize its relevance and acceptability to others. Input was obtained by interviews and focus groups. The resulting intervention was four 90-min small-group sessions that provided educational information, direct instruction, practice and peer-to-peer problem-solving. A pre- to post-non-randomized design was used to evaluate the intervention's effect to increase or maintain parents' twice daily brushing. RESULTS: Intervention participants were 67 primary caregivers of children under six years of age. Of the 67 initial participants, 50 completed a post-intervention questionnaire administered 4 to 8 weeks following the intervention. The proportion of parents who reported brushing their young children's teeth twice a day increased significantly from 59 per cent prior to the intervention to 89 per cent post-intervention (McNemar's X(2)  = 10.71, P = 0.002). There were concomitant and statistically significant increases over the study period in parents' confidence for brushing twice a day, attitudes about the importance of brushing and their self-efficacy for tooth brushing. Parents' knowledge of children's oral health, assessed by a 15-item scale developed for this study ('Things to Know About Baby Teeth'), also increased significantly. CONCLUSIONS: Twice daily tooth brushing is a low-cost, effective strategy to reduce the risk of childhood caries. As demonstrated here, community-based efforts can help parents achieve this important health behaviour.

Parent-reported distress in children under 3 years old during preventive medical and dental care.

PURPOSE: This study examined factors related to young children's distress during preventive oral health visits. Additionally, associations between parent-reported child behaviour during the dental visit and during previous medical visits were tested. METHODS: One hundred twenty-two children under 3 years of age enrolled in a government insurance programme for low-income children were seen for examination, prophylaxis, and fluoride application at a university-based dental clinic. Child distress was rated by parents on a numerical rating scale. RESULTS: The average age of children enrolled was 23.5 ± 7.3 months. The majority (55.7 %) were judged to have little or no distress pre-examination. Mild or no distress during the examination was reported for 42.6 % of the children and severe distress was reported for 39.4 %. Intensity of distress during the examination was not associated with the child's age, gender, dental health, or previous experience with dental care. Distress was also unrelated to the caregiver's education level or own dental health. Intensity of distress was associated with the child's pre-dental examination distress and distress during prior medical examinations and injections. CONCLUSIONS: Dental professionals can better anticipate child distress by assessing children before a dental examination and enquiring about previous medical experiences. Strategies to prepare parents and alleviate distress may help children cope with the preventive dental visit.

Implementation partnerships in a community-based intergenerational oral health study.

BACKGROUND: University-community partnerships are a common strategy used in implementing community-based health promotion trials, yet few published studies report these interactions in detail. "Baby Smiles" was a five-year intervention study in Oregon, USA. The study involved 400 low-income women during and after pregnancy across four rural counties. In this report, we describe and assess four university-community health partnerships formed to support the intervention. METHODS: A community health partnership advisory group for the study was established in each of the four participating counties. Group membership ranged from 9 to 23 individuals. A survey was administered to the groups five times in a 2.5 year period. The survey asked members' opinions of the intervention's goals, scientific basis and relevance to their organisation. Questions also asked about members' knowledge of oral health, beliefs about access to dental care for low-income pregnant women and children in their county and how their organisation functioned. RESULTS: There was strong overall support by each partnership group despite differences in the groups' structure, foci and turnover in membership during intervention period. Responses to specific survey items indicating misinformation or negative opinions about oral health care were used to address weaknesses in study implementation throughout the conduct of the study. CONCLUSION: Systematic monitoring of community support for a multi-year oral health intervention is feasible and can identify potential barriers to address while the study is underway.

A first look: determinants of dental care for children in foster care.

PURPOSE: This hypothesis-generating study sought to identify potential determinants of dental care use and oral health among children living in foster care. METHOD: Using a grounded theory approach, fourteen key informant interviews were conducted among health and social services professionals experienced with children in foster care and families in western Washington State. RESULTS: The identified potential determinants of oral health and dental use among children living in foster care included: (1) linguistic and cultural barriers; (2) lack of dentists willing to accept children's Medicaid dental insurance; (3) lack of resources available to case workers (i.e., large caseload burden) (4) lack of federal funding for specialized dental care; (5) lack of systematic health record-keeping; (6) child transience, leading to the lack of a dental home; (8) foster parents' competing needs; (7) child behavior problems; and (9) lack of dental "buy in" from adolescents. CONCLUSION: Additional studies are needed to determine whether children living in foster care achieve oral health, and the extent of their unmet dental need.

Quality of life and health-risk behaviors among adolescents.

PURPOSE: To assess the association between health-risk behaviors and self-perceived quality of life among adolescents METHODS: A sample of 2801 students (957 seventh and eighth graders and 1844 ninth through twelfth graders) completed the Teen Assessment Survey (TAP) and the surveillance module of the Youth Quality of Life Instrument (YQOL-S). TAP responses were used to determine health-risks related to tobacco use, alcohol use, illicit drug use, and high risk sexual behavior. Separate multivariate analyses of variance showed mean differences in contextual and perceptual items of the YQOL-S for each health-risk behavior. Differences among engagers (adolescents who often engage), experimenters (occasionally engage), and abstainers (never engage) in the health-risk behavior were evaluated by gender and junior/senior high school groups. RESULTS: In general, adolescent abstainers reported higher quality of life (QoL) than engagers and experimenters on YQOL-S items. Adolescents who engaged in multiple risk behaviors scored even lower than those who engaged in only one health-risk behavior. Experimenters tended to rate their QoL more similar to that of abstainers than to that of engagers. CONCLUSIONS: The framework of QoL proved useful in the evaluation of adolescents' engagement in health-risk behaviors. Additionally, assessing the areas of QoL that differ between the groups may provide information for planning interventions aimed at risk reduction among engagers and experimenters.

PrePare: a program of enhanced prenatal services within health-maintenance organization settings.

This paper presents the conceptual framework and implementation strategies of a relationship-focused behavioral intervention for pregnant women and their families. The program, PrePare ('Prenatal Parenting'), was designed as a prenatal precursor to the pediatric health care model, Healthy Steps. PrePare includes preventive intervention elements that address parents' universal concerns about pregnancy and parenthood, as well as specific activities to support optimum pregnancy health and reduce high-risk behaviors. As described here, the program is embedded within a large not-for-profit health-maintenance organization (HMO). Delivery of the prenatal component is carried out by Healthy Steps interventionists through three home visits and telephone follow-up during mothers' second and third trimesters of pregnancy. An evaluation of program outcomes is underway. The design compares three groups of families, those who receive PrePare followed by Healthy Steps, Healthy Steps alone and a usual HMO-practice comparison. It is hypothesized that initiating expanded services during the prenatal period will lead to increases in reported patient satisfaction, provider satisfaction and organizational efficiency within the health care delivery system.