Healthy Smiles 4 life Introduction LS2 Team members:

Transcription

1 Healthy Smiles 4 life Introduction LS2 Team members: Christine McKay Portfolio Manager, Oral Health & Child Health, CMDHB Satha Kanagaratnam Clinical Director, Auckland Regional Dental Service Patsy Prior - Operations Manager, ARDS Dianne Houston Logistics and Operational Support Manager Sneha Shetty Improvement Advisor, Ko Awatea Danni Farrell Project Manager, Ko Awatea Robyn Mahood, Debbie Rowley, Keita Tahana, Karyn Thwaites- Valter, Lyn Henry (ARDS) Annette King (Plunket), Fonofili Parkinson (Southseas), Christine Ripia (Papakura Marae), Pooja Sohal (Raukura) Lucy Kinikini (Mighty Mouth, Hereraina Eketone (Mighty Mouth /Smilecare)

2 Aim Statement The aim is to have ALL children pain free and disease free, with functional dentition from an early age, with a full set of baby teeth to enable eating, and speech development, plus a positive dental self esteem. We want to REDUCE and even ELIMINATE oral inequities by preventing early childhood caries in preschool Maori and Pacific children, and those from high deprivation communities, and Maximise use of our funding for children s community oral health services in a campaign to prevent early childhood caries through early fluoride varnish application, intensive oral health education to parents/caregivers including nutritional advice

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4 Aim Statement: Preschool Toothbrushing Program The Preschool toothbrushing Oral Health education program aligns with the project aim, however does not deliver to younger babies and Mums at home where cariogenic behaviour starts Preschool centre staff are trained in oral health, oral hygiene practices, and better nutrition choices for preschool children. Children receive 3 simple messages brush your teeth twice a day, eat healthy food and drink healthy drinks, go to the dental clinic. Games matching healthy food with healthy teeth are an integral learning activity. Songs and posters reinforce key messages - interactive education, experiential, embedded messages Daily tooth-brushing is supervised by teachers Liaison with Dental service follow-up

5 Aim Statement: healthy nutrition messaging Educational mat times and integrated games at ECE align to our aim but do not reach mums and babies before start of unhealthy foods and drinks and incidence of dental caries

6 Aim Statement: oral health education Supervised toothbrushing at ECE align to our aim and assist in OH education but do not reach Mums and babies before dental caries start

7 Storytelling: Communities Voice evaluation of children and their mums in the MMTB program Evaluation of the Mighty Mouth Tooth brushing program (Litmus ) A comparison of pre-school children (survey of 46 children aged 3-4 years old) participating in the Mighty Mouth Tooth-Brushing Program with pre-school children (matched) not in the Program clearly demonstrates their involvement in the Program is positively impacting on: Twice daily tooth brushing and spitting after cleaning. Mothers of children also report increased frequency of tooth brushing and requests for toothbrushes and toothpaste at home from their pre-schoolers involved in the Program Pre-schoolers knowledge of reasons for visiting a dental clinic Pre-schoolers knowledge about healthy food and drink choices. Overall the Mighty Mouth Tooth-Brushing Program is most successful at changing tooth brushing knowledge and habits over knowledge and behaviour of healthy food and drink choices. Matching healthy food with healthy teeth is an integral part of learning and teachers supervise daily tooth brushing. MMTB Mothers (survey 148 mums) also report increased frequency of tooth brushing and flossing their own teeth. This is at levels higher than the national population of Māori and Pacific women aged 18 and 49 years and women in the OHDIP Trial Initiative. MMTB mothers also recognise the importance of taking care of baby teeth and agree it is as important as taking care of adult teeth.

8 Socio-cultural differences is a key issue The incidence of early childhood caries is starting earlier with eruption of baby teeth and the wider choice of sweetened drinks and foods All children start caries free at birth, and at 1 year old Pacific, Maaori and Asian children are showing caries (tooth decay). At 2.5 years children generally have all their baby teeth (deciduous). Dental decay is rising between 1 and 2 years for Pacific, Maori and Asian due to lack of toothbrushing, and poor diet, lots of sugar beverages and foods, and lack of engagement with dental services. Improvements will come from earlier engagement, intensive education, and application of preventative treatments Health literacy for Oral Health is poor Myth that baby teeth don t matter they will fall out and are replaced with strong permanent teeth Myth that oral health is disconnected to general health & well-being Community behaviour that dental care is only for events of pain and infection Self-focus of current health messaging is incongruent with cultural values particularly Maori, Pacific, Indian / Asian This influences how functional health message are received, and the response to behaviour change messages This will also influence the model required to get the message heard, accepted, change trialled, change normalised and embedded We need the messages to be socialised and passed on to be normalised

9 What does the data tell us Children can be enrolled for free dental care from birth. It s important to look after baby teeth as decay in the first teeth will be painful and can affect the child s eating, speech, sleeping, learning and development, and may affect their permanent teeth as well. Generally preschool enrolment and examination (utilisation) has improved across the region but is still not at target of 95% enrolment and 85% examination Inequities are more evident in Counties Manukau children in enrolment eg only 73% of Māori children aged 0-4 years enrolled, 85.9% of Pacific, 76.6% of Asian (1 Jan 2017) versus a target of 95%; and utilisation is well under the other DHBs Examination and utilisation of dental services is dependent on enrolment and parental engagement to attend an appointment, and on clinical capacity to see the children CMDHB, 31 Dec 2016 Pre-school children (age 0-4) Total Enrolled Total Eligible Population Percentage Enrolled Number examined % of enrolled population examined % of eligible population examined Asian 7,526 9, % 4, % 49.9% European / All Other 9,671 9, % 5, % 64.1% Māori 7,297 9, % 3, % 36.3% Pacific Only 9,789 11, % 5, % 45.2% Total - all ethnicities 34,283 40, % 19, % 48.5%

10 What is the data telling us? Oral health outcomes are measured by the % of eligible population are caries free at 5 years and the mean dmft (decayed missing or filled teeth). Modest improvements over time for Māori, Pacific and Asian children, however persisting equities versus European. Inequities are evident as at five years of age, in 2016, only 30% of Pacific children in the district were caries free, compared to 38% of Māori, and 56% of Asian / Other and 75% of European CMH % incidence of population Caries free at 5 years by ethnicity Actual 2011 Actual 2012 Actual 2013 Actual 2014 Actual 2015 Actual 2016 Actual * Asian 56.1 Maaori Pacific All Other European 74.8 Total

11 Define the Problem persisting Oral Health disparities from early age Early Childhood Caries (ECC) or dental decay is most prevalent chronic and irreversible disease in the Western World. ECC has strong links to a number of systemic diseases, including rheumatic fever, a major health issue for Māori and Pacific children In New Zealand disparities still exist in oral health by ethnicity, deprivation level, and age group; particularly evident in Counties Manukau where higher rates of ECC plague Maori and Pacific Inequities persist for non-european children in the Counties Manukau District. This high prevalence of childhood caries in CM Health, combined with low engagement with the dental service, leads to poor performance on health indicators associated with oral health. All children start caries free at birth, and at 1 year old Pacific, Maaori and Asian children are showing caries (tooth decay). At 2.5 years children generally have all their baby teeth (deciduous). Dental decay is rising between 1 and 2 years due to lack of toothbrushing, and poor diet / lots of sugar beverages and foods, and lack of engagement with dental services. Chart - Incidence of caries free at age year by ethnicity shows the % of children by preschool age that are caries free ie no decayed missing or filled teeth. At 3 years inequities are evident - Pacific 39% have caries - Māori 28% have caries - Asian /other 20% have caries - European 7% have caries % caries free 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Counties Manukau Preschool percentage of population caries free by age year, % 98% 86% 80% Asian 86% 69% 75% 72% European 65% 61% 56% Maaori 50% 41% 38% Other 30% Pacific Preschool age year

12 The problem: the equity gap Māori and Pacific children in particular have an equity gap compared all other children in that less than 40% go to school at five years old free of caries, decayed missing or filled teeth versus 56% Asian and 75% of European. This means they have more appointments, fillings and extractions and overall pain and discomfort. The gap in enrolments and engagement in dental services from 0-2 years is marked vs European We also have a gap in Māori and Pacific health workers engaged in oral health.

13 Measurement Summary Participation in the healthy smiles FVA initiative Engagement of Maori and Pacific families in dental services Description Measure Current performance Target performance Outcome Measure Preschool Children engaged in prevention program and dental services Number and % of Maori and Pacific children enrolled in dental service by 12 months and engaged in FVA program 68% of Māori children aged 0-4years enrolled, 80% of Pacific, 87% of Asian 59% of enrolled examined 47% of eligible population are examined 95% of Maori and Pacific infants enrolled in dental service by 12 months of age 50% of Maori and Pacific infants to have FVA by 12 months 85% examination by 18 months % Caries incidence by age year by ethnicity % caries free at five years Process Measure Collaboration identifying and targeting children between WCTO / NIR / ARDS produces a list for FVA program Number and % of children parents are informed and consented Number and % of children enrolled at 5 months and receive oral health education Number and % of children visited for FVA at 12 months - Home - Childcare setting Balance Measure Baseline data enrolment, examination, caries, age at which caries commenced % enrolled 0-4 years by ethnicity % of enrolled examined, See chart % of eligible population examined

14 Efficacy & measurements of success - reference EVALUATION Can we measure success short term Number of children with FVA at home visit; siblings Number of children with FVA application at ECE Earlier preschool enrolments, engagement with dental Kids tooth-brushing every day, cleaner mouths Healthier nutrition, kids articulate better choices Increased knowledge Mums and children, dental survey (refer Litmus MMTB survey) Desirable long term outcomes Less treatments Early childhood caries reduced; i.e. Caries free % at 5 years increased Age at which ECC starts is delayed and % caries free in increased per age year DMFT (decayed missing filled teeth) at year 8 of school reduced Good data, reliable Evaluation - survey Knowledge increase; attitude change Changed habits tooth-brushing Better choices, changed habits diet Support healthy food policy at preschool ISSUES Efficacy Various options inappropriate for preschool children or ineffective issues in measurement, reliability, validity Some reports largely anecdotal and subjective Transient population significant impediment Continuity Compliance of preschool, family Salivary test for strep mutans not readily available or reliable if desired to evaluate reduction in strep mutans Confounding issues Sibling / Parents influences +ve /-ve Over-coming the Fluoride issue Affordability of program across regions WCTO / DSW home visits with hard to find families Dental clinic visits attribution issue to evaluated financial and non-financial benefits Preschool Staff changes, and motivation Reinforcing experiences ve /+ve Cost/effectiveness of programs Funding constraints

15 Driver diagram Outcome Primary drivers Secondary drivers Specific change ideas Change concepts Oral hygiene Dental misconceptions Additional Preschools Toothbrushing program Supply toothbrushes and toothpaste to high dep families We want to reduce oral health inequities by preventing early childhood caries in preschool Maori and Pacific children, and high deprivation communities Health Literacy Patient access to service Service access to patient Nutrition - Sugar consumption Feeding techniques Parenting techniques Parental awareness of when and where to go to dental clinics Flexibility around appointments Working with other agencies/ providers to enrol /check infants & Preschoolers Healthy Smiles program OH Education and FVA for infants 12 months, repeat every 6 months Prevention program Early Childhood caries infants- intensive oral health education parents care-givers; FVA Extend dental service hours to twilight clinics and Saturday clinics Health agency collaboration to find Preschoolers Clinical examine at 1 year of age, prioritise target population Expand - Preschool toothbrushing program targeted M&P/ High dep at 150/510 CMH preschools to all High deprivation communities Healthy Smiles program early intervention FVA, infants 12 months, intensive education mums/ caregivers, repeat every 6 months Collaboration between WCTO, NIR and Dental Support Workers to identify children for FVA intervention Clinical examine from 1 year of age, prioritised target population Provision of Service Dental support health workers for promotion /education; need cultural competencies Recruit Dental support health workers for preschools / Marae / churches, and home visit parallel with WCTO Recruit Dental Support health workers / cultural competencies Culturally relevant health workers using mix of Well child nurses, dental support workers Collaboration NIR / Kidslink / WCTO with Dental to find infants/ Preschoolers

16 Building up a change package: Healthy Smiles Healthy Smiles education and FVA from 12 months age PDSA - using dental support workers in ECE to deliver HS FVA PDSA using dental support staff with WCTO nurses and HW to deliver HS / FVA home visits Early Childhood Caries prevention program Clinical examination of children at 12 months of age PDSA Lift the Lip by WCTO / DSW with referral to ARDS for appointment PDSA children given appointments to come into ARDS clinic increased availability of appointments eg Saturdays PDSA lift the lip in GP practice with referral to ARDS for appointment Workforce dental, well child PDSA 1 workforce health literacy and FVA application training for WCTO / DSW home visiting and ECE visiting PDSA 2 workforce health literacy training for clinical and non-clinical dental team extension health literacy training for Primacy care

17 Highlights: biggest learnings Unhealthy diets linked to childhood obesity are a key determinant of health; less publicised is the link with poor oral health, dental disease and general health & well-being. Oral health is still outside of general Health & Well-being however can be a conduit for healthy nutrition messages to be given in a compelling context. The timing is right for our project to align with childhood obesity however we are pitching our learning and intervention opportunities at 12 months of age To get step change in improved oral health, we need to change knowledge, attitudes and behaviours, oral hygiene, engagement with dental services, healthy nutrition. And collaborate with Well Child Tamariki Ora providers and ECE Getting started! Maintaining workload

18 Where are we at: Where to: Lots of data/ information/ ambitions Examples of Childsmile UK and Nelson - NZ Even more Endorsement from senior management Inclusion in the regional preschool strategy plan Project plan Recruitment strategy DSW- ARDS vs WCTO Health Literacy development Test resources in development develop workforce modules Consumables-fluoride dose sticks, gloves, mask, Test plan for disposal process Project implementation plan Recruit DSW- ARDS Health Literacy resources Train workforce Procurement Consumables-fluoride dose sticks, gloves, mask, Develop plan for disposal process Transportation Test localities Test home visits Test ECE visit Evaluation Assessment key learnings Review period Roll out to other localities