Improving Pediatric Health: Biobehavioral Approaches to Childhood Disease Management

Web Sites

American Dental Association
The Web site of the American Dental Association contains a wealth of information, including a section on tooth decay and caries.

Center to Address Disparities in Children's Oral Health (CAN DO)
The CAN DO is a multiproject research center funded as a cooperative agreement by the National Institute of Dental and Craniofacial Research. Their primary focus is preventing early childhood caries (ECC). Mothers and Youth Access (MAYA) is one of their projects.

Children's Dental Health Project
The Web site contains publications and program information about children's oral health, particularly on issues involving access to care, financing programs, health disparities, and work force.

Columbia University School of Social Work
The Columbia University School of Social Work has a number of centers dedicated to understanding vulnerable populations and devising policies and programs to improve social conditions.

Detroit Center for Research on Oral Health Disparities
The Detroit Center for Research on Oral Health Disparities aims to promote oral health and reduce disparities within the community of low-income African American children (0-5 years) and their main caregivers (14 + years) living in the City of Detroit.

Global Child Dental Fund
The mission of this UK-based fund is to significantly improve the dental health of children worldwide by developing public-private partnerships, coordinating services and national and/or regional educational programmes, promoting effective evidence-based oral health messages, and shaping global dental leaders to drive the agenda.

Health Resources and Services Administration
In addition to its other roles, the Health Resources and Services Administration promotes the widespread availability and use of digital networks to improve access to health care services for people who are uninsured, isolated or medically vulnerable.

Institute for Oral Health
The Institute for Oral Health collaborates with America's leading experts in health care to gather data, insights, and potential solutions for improving the efficiency and effectiveness of dental care treatment, delivery, and policies. Their next conference is October 15-16, 2009.

Motivational Interviewing
This Web site is intended to provide resources for those seeking information on motivational interviewing. It includes general information about the approach, as well as links, training resources, and information on reprints and recent research.

National Maternal and Child Oral Health Resource Center
The purpose of the National Maternal and Child Oral Health Resource Center (OHRC) is to respond to the needs of states and communities in addressing current and emerging public oral health issues. OHRC supports health professionals, program administrators, educators, policymakers, and others with the goal of improving oral health services for infants, children, adolescents, and their families. The resource center collaborates with federal, state, and local agencies; national and state organizations and associations; and foundations to gather, develop, and share quality and valued information and materials.

New York Academy of Medicine
The New York Academy of Medicine advances the health of people in cities. An independent organization, NYAM addresses the health challenges facing the world’s urban populations through interdisciplinary approaches to innovative research, education, community engagement and policy leadership. The DiSH project is part of research at the Center for Urban Epidemiological Studies.

WIN for Asthma
The WIN for Asthma program aims to decrease asthma-related hospitalizations, emergency department visits, and school absences in the Northern Manhattan community and to improve the quality of care provided to children with asthma by offering group and individualized training, and Quality Improvement (QI) services to health care providers in the northern Manhattan area.

Journal Articles

Introduction

Krol DM, Nedley MP. 2007. Dental caries: state of the science for the most common chronic disease of childhood. Adv. Pediatr. 54: 215- 239.

Krol DM. 2004. Educating pediatricians on children's oral health: past, present, and future. Pediatrics 113: e487-e492. Full Text

Starting Point

Fisher-Owens SA, Gansky SA, Platt LJ, et al. 2007. Influences on children's oral health: a conceptual model. Pediatrics 120: e520-e520. Full Text

Ismail AI. 2009. The ADA's Community Dental Health Coordinator (CDHC): a model to improve access to dental care. Pa. Dent. J. (Harrisb). 76: 27-29.

Ismail AI, Lim S, Sohn W, Willem JM. 2008. Determinants of early childhood caries in low-income African American young children. Pediatr. Dent. 30: 289-296.

Jenson L, Budenz AW, Featherstone JD, et al. 2007. Clinical protocols for caries management by risk assessment. J. Calif. Dent. Assoc. 35: 714-723.

Mouradian WE, Huebner CE, Ramos-Gomez F, Slavkin HC. Beyond access: the role of family and community in children’s oral health. Journal of Dental Education 71: 619-631.

Ramos-Gomez F, Chung LH, Beristain RG, et al. 2008. Recruiting and retaining pregnant women from a community health center at the US-Mexico border for the Mothers and Youth Access clinical trial. Clinical Trials 5: 336-346. (PDF, 134 KB)

Ramos-Gomez F, Crall J, Gansky SA, et al. 2007. Caries risk assessment appropriate for the age 1 visit (infants and toddlers). CDA Journal 35: 687-702. (PDF, 1.11 MB)

The Toolbox

Theory at a Glance: a Guide for Practitioners (PDF, 3.36 MB)
Explains key theories in health promotion and behavior in detail, with specific examples.

Bonner S, Matte T, Rubin M, et al. 2006. Validating an asthma case detection instrument in a Head Start sample. J. Sch. Health 76: 471-478.

Harrison R, Benton T, Everson-Stewart S, Weinstein P. 2007. Effect of motivational interviewing on rates of early childhood caries: a randomized trial. Pediatr. Dent. 29: 16-22.

Purmort J, Coady MH, Bucciarelli A, Bonner S. 2008. Asthma education in a subsidized preschool setting. JHCPU 19: 1241-1247.

Weinstein P, Harrison R, Benton T. 2006. Motivating mothers to prevent caries: confirming the beneficial effect of counseling. J. Am. Dent. Assoc. 137: 789-793. Full Text

The Players

Kramer GA, Albino JE, Andrieu SC, et al. 2009. Dental student assessment toolbox. J. Dent. Educ. 73: 12-35.

McKay MM, Chasse KT, Paikoff R, et al. 2004. Family-level impact of the CHAMP Family Program: a community collaborative effort to support urban families and reduce youth HIV risk exposure. Fam. Process 43: 79-93.

Pinto RM, McKay MM, Escobar C. 2008."You've gotta know the community": minority women make recommendations about community-focused health research. Women Health 47: 83-104. Full Text

The System

Fairbrother G, Simpson LA. 2009. It is time! Accelerating the use of child health information systems to improve child health. Pediatrics 123: S61-S63. Full Text

Sponsorship

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Academy Friends

"This is not a dental meeting. Nor is it a clinical, or science, or child, or policy, or systems development, or collaborative meeting—it is all of those things," declared Burton Edelstein of Columbia University College of Dental Medicine. "It is a room full of raw potential with a simple goal: to do the hard work to improve the lives of children by improving their ability to obtain and maintain health—including oral health—particularly for children made vulnerable by their social condition."

With those words, Edelstein, an organizer of the May 1, 2009, meeting on biobehavioral interventions for children's health, set the stage for a day of presentations and discussion aimed at improving these interventions overall, and embedding children's oral health firmly within the context of pediatric health.

"Bad teeth? So what?"

Pediatrician David Krol of the University of Toledo provided an overview of unmet needs and disparities in the management of children's oral health, an often overlooked aspect of pediatric health. Dental caries is the most prevalent disease of childhood in the United States (five times more common than asthma), and the prevalence is rising, Krol stressed. Close to 50% of children have a visible cavity before age 6, a condition known as early childhood caries, or ECC.

"Parents may accept caries as normal, or think baby teeth aren't important. But we know that bad teeth can progress to pain, tooth loss, infection, dysfunction and—rarely—death," said Krol. Children experiencing tooth pain may exhibit problem behaviors and have difficulty concentrating in school; soft, decaying teeth also interfere with eating and can harm self esteem.

Many people, including medical students, are not familiar with the concept of dental caries or find it confusing. To explain that caries is a disease process, Krol compares the condition to diabetes. "You don't wake up one morning and have a diabete, just like you don't wake up and have a carie. Caries is disease process that can lead to a cavity."

A multifactorial approach to disease prevention is required.

Both public and private payors often reward repair (i.e., filling cavities) over disease management, just as they do in obesity (i.e., providing reimbursement for treating hypertension, but not for weight management), Krol continued. But treatment addresses symptoms, not root causes. "ECC is a multifactorial chronic disease and so the approach to the disease process needs to be multifactorial," he said. Since the risk factors are known, ECC can be prevented or suppressed with appropriate interventions. Once established, the disease has to be treated surgically, but the focus should be on preventing the process that led up to it.

A slew of environmental stressors, from economic hardship to lack of access to care to competing priorities, often thwart parental efforts to safeguard their children's teeth. And so, as is the case for managing other childhood diseases, "a team approach is critical," Krol said. "We need to promote early intervention approaches with consistent messages [from pediatricians, dental providers, and others] that are biologically rational, evidence-based, and behaviorally oriented. These approaches need to be family-centered and applied as early as possible."

Behavioral models that are proving successful in detecting and managing other chronic diseases of childhood—especially those that focus on the underserved—"may be applied to oral health with similar positive results," Krol suggested.

Speakers:
Mary McCord, Columbia University
Francisco Ramos–Gómez, University of California, Los Angeles
Amid Ismail, Temple University

Highlights

• A child's oral health is impacted by a wide array of factors that include genetic and biological factors, the social environment, the physical environment, health behaviors, and accessibility and scope of dental and medical care.
• In underserved populations, the community health worker—not the clinician—is key to behavior change.
• Child health interventions must be personalized, and target the family, not just the child.
• Similarly, public health programs such as Medicaid need to focus not just on children, but also their caregivers.

"Every asthmatic is different"

A child's health is affected by family-level and community-level influences that are well described in a conceptual model developed by Susan Fisher-Owens, of the University of California San Francisco's Center to Address Disparities in Children's Oral Health (CAN DO). The model incorporates five key domains of health determinants from the population health literature: genetic and biological factors, the social environment, the physical environment, health behaviors, and dental and medical care. All of the domains must be addressed in an effective intervention.

Mary McCord of Columbia University presented a case study that illustrates one holistic approach to pediatric health care: a hospital–community childhood asthma management/intervention program aimed at improving asthma outcomes in children with poorly controlled asthma. The 12-month program, WIN for Asthma, is underway in the Washington Heights/Inwood section of New York City. The population has characteristics similar to those of families with oral health disparities:

• Poverty
• Low levels of education
• Immigrant status: 70% Hispanic, mostly Dominican
• Social and linguistic isolation
• Overcrowded living conditions
• Served by complex and fragmented health systems
• Distrust of local health centers

One key notion that underlies the intervention is that every asthmatic is different. From the standpoint of a clinician, "of course, there's a level in which they're not different, in that they all need inhaled steroids," McCord acknowledged. Beyond that, however, differences abound with respect to the mix of psycho-social factors that influence the asthmatic child's family, attitudes about medications, knowledge and understanding of asthma, access to care, the presence of allergy, and exposures to environmental triggers such as cigarette smoke. Any intervention must take those parameters into consideration, as well as other factors—such as domestic violence—that may be unrelated to asthma per se, but are also acting on the child and family, and may affect other aspects of health as well as adherence to an intervention.

Another key concept is that the community health worker—not the clinician—is the centerpiece for behavior change. In the WIN program, these workers are supervised dually by the community-based organization (CBO) that hires them and by the medical center. The CBO trains them in engagement and outreach skills, while the medical team teaches asthma-related knowledge and skills, including behavior change.

Community-based organizations provide intensive support during the first three months of the WIN program.

Because many families feel hopeless in the face of asthma, finding it difficult to cope with a disease that comes and goes, the WIN program emphasizes self-efficacy, providing facilitated access to services and strategies to reduce stressors. CBOs educate participants about the chronic nature of asthma and the purpose of the different asthma medications, assess the family's needs and strengths, check the home for potential asthma triggers, and set specific goals with the family. CBOs provide intensive support during the first three months, tapering off to bi-monthly check-ins with a final follow up after one year.

To date, 92 families have graduated from the program. McCord and her colleagues documented a 78% increase in the number of families who reported feeling in control of their child's asthma (self-efficacy) and a 48% decrease in number of families with concerns related to their child's medications. Asthma morbidity outcomes were also impressive: a 54% decrease in hospitalizations; a 38% decrease in emergency department visits; a 53% decrease in symptom-days; and a 30% decrease in asthma-based school absences.

"Personalismo" thwarts ECC

On another front, Francisco Ramos–Gómez of the University of California, Los Angeles' Division of Pediatric Dentistry, has been tackling ECC among economically disadvantaged Mexican-Americans, whose children are five times more likely to have ECC than the general U.S. population. Shortly after joining the UC faculty, Ramos realized his group would be handling every child under age three in the area, all of whom required hospitalizations and very aggressive treatment and care. ECC was a major problem and an epidemic.

Recognizing that they could not effectively treat children without also involving their mothers, in 2002, Ramos and an interdisciplinary team of practitioners from CAN DO, in collaboration with colleagues at the San Ysidro Community Health Center and members of the border town community, launched the Mothers and Youth Access (MAYA) ECC prevention project. The randomized clinical trial recruited 556 women in their sixth month of pregnancy and followed them until their children were three years old. Innovative recruitment strategies, such as holding group baby showers, were particularly effective. Efforts were made to create value for oral health in the caregivers (targeting their infants) and incorporate it into a prevention plan, rather than allowing it to remain in the province of urgent care—that is, dealing with chronic infectious disease and rampant decay in the hospital emergency department.

Baby showers and parties are part of the personalismo approach.

Involvement of women in the community, in the form of a community advisory board, was key to both recruitment and retention, Ramos said. The women came up with the name, MAYA, as well as strategies to personalize the intervention ("personalismo") to show mothers that they cared and wanted to help. Personalismo included "hands on" participation, with case management that included sending birthday cards and making phone calls on the child's birthday, holding baby showers and parties, providing free transportation and dental discounts for the family as well as post-partum depression assistance.

Also key were the "promotoras"—community outreach workers or patient navigators who helped participants navigate the health services system and facilitated interactions with providers by providing translation and by communicating the concepts needed for health literacy. Taken together, these strategies contributed to a 53% retention rate before randomization (of the initial 556 women, 361 decided to enroll in the program) and 81% afterwards—remarkable for a border health project with a highly mobile population, Ramos acknowledged.

MAYA compared the three-year incidence of caries in children using various interventions, including chlorhexidine rinses, fluoride varnishes, and oral health counseling for parents. But beyond looking at the effectiveness of specific intervention protocols (data are still being analyzed), the study has longer term objectives to not only reduce the incidence of ECC, but also to improve children's access to preventive oral health services overall, provide health information to underserved pregnant women and new mothers, and to reduce oral health disparities and bring oral health value into their daily lives and routines.

During the study, Ramos and his colleagues learned that for some women, the trial was their first entry into any medical or health-related services. The team uncovered a fair amount of previously undetected post-partum depression. "Suddenly, we were the entry point not just for oral health but also for mental health and other providers," Ramos explained. Fortunately, all of the services were available at the San Ysidiro Community Health Center.

Lessons learned from MAYA include the need to:

• involve the mother in any oral health care intervention
• include a community advisory board that can help with translation and health literacy (i.e., it is not enough to translate words—the team needs to communicate concepts, as well)
• exhibit social and cultural sensitivity (in this case, sensitivity to fears of immigration authorities, the presence of drug abuse)
• understand traditions (i.e., the importance of "la familia" and of the mother as the core leader)

“This is part of our life crusade to eradicate children’s dental pain and suffering by creating an effective and sustainable Prevention Management Model. The challenge for all of us is to aim for a cavity-free generation," Ramos stressed. "I wonder if it will happen in my lifetime."

"Can't just think of a child as teeth"

Like the presenters before him, Amid Ismail of Temple University stressed, "If we don't look at children in the context of their communities—where they live and how they live—our health interventions won't work." As evidence from studies across disciplines shows, risk factors experienced early in life—even in utero—may have dramatic effects on health throughout the life cycle, he said. Taken together, these concepts support the notion that dental providers "can't just think of a child as teeth."

In an effort to better understand the socio-economic systems and stressors that children living in poverty face, with a view towards developing more effective oral health interventions, Ismail and his colleagues followed a cohort of more than 1000 children aged 0-5 years and their caregivers over a four-year period as part of the Detroit Dental Health Project. Participants had the following characteristics:

• Household annual income averaged less than $10,000.
• Many parents did not have a high school diploma.
• Families had an average of one to two children.
• Eighty percent of parents were depressed; 50% of those who were not depressed had depressive symptoms.
• Forty-six percent of caregivers were obese; of those, 85% remained obese after four years and 20% of the non-obese became obese.
• Obese African-American children in this cohort did not "outgrow" their obesity, unlike African-Americans in the general U.S. population.

The researchers found that in this population, among children who received only preventive oral health care, 75% of cavities left untreated at baseline remained cavities over the study period. This is the same percentage of untreated cavities found in families that made no dental visits. By contrast, when treatment visits were covered (by Medicaid), less than one-third of untreated cavities remained untreated.

While treatment is clearly important, an effective oral health program for children needs to do more than simply treat teeth, Ismail emphasized. It also must address all the other factors that promote disparities. "ECC is not just a dental problem, but a societal one," he said. Dentists need to be talking about poverty as part of oral health prevention, and public health programs such as Medicaid need to focus not just on children, but also their caregivers, he urged. "One point interventions don't work," Ismail concluded.

Speakers:
Susan Witte, Columbia University School of Social Work
Judith Albino, University of Colorado, Denver

Highlights

• Parents, like their children, are influenced by many factors in their daily lives that affect their attitudes and behaviors around their children's oral health.
• It takes a village—of youth, parent advocates, peers, clinicians, and services researchers—to create a successful health behavior change program.
• Dental providers believe that they, rather than their patients or specific treatments, make the difference in oral health outcomes; this reinforces a paternalistic approach.
• Dental providers must listen more and talk less.

Collaborating with parents: Part one of the dyad

Parents are key players in any ECC prevention or pediatric health care program. Susan Witte of Columbia University's School of Social Work delved more deeply into the research underpinning successful behavioral change interventions in this critical population. Echoing Philip Weinstein, she stated, "If we don't think of collaborating with parents—if we think we're serving or instructing them—our ECC interventions won't work."

Witte referred to lessons learned from the child mental health literature—in particular, the work of Mary McKay, a professor at Mt. Sinai School of Medicine. That literature shows that parents, like their children, are subject to multiple factors that influence their day-to-day lives and, by extension, their attitudes and behaviors around their children's oral health. An intervention research model groups these factors into two categories—moderators (predisposing factors that are difficult to change) and mediators (factors that can be influenced over the long term), both of which affect outcomes, Witte explained.

The intervention research model breaks out moderator factors that influence an outcome but are difficult to change and mediator factors that are more malleable.

Parents of children with ECC share many characteristics with parents whose children have mental health concerns. They are often single parents with low social support who are coping with poverty (especially in urban settings) and exposure to violence. Frequent housing moves, English as a second language, and a bicultural lifestyle compound their challenges.

Specific barriers to care include stigma (i.e., being part of an underserved population, or having a condition such as mental illness), racism/discrimination, lack of social competence, lack of information, lack of transportation, difficult delivery and reimbursement systems for health care, as well as providers who are unresponsive to parents' needs and concerns.

In fact, parents' attitudes toward services and providers can drive a program forward or bring it to a halt. "If a parent believes that a child will improve without professional intervention, that's a significant concern for ECC," Witte observed. As David Krol noted earlier, parents may think that baby teeth aren't important—only primary teeth count.

Similarly, if providers are difficult to reach and deal with, or if the parent hasn't had positive dental experiences herself, then she is less likely to be adherent to an intervention for her child. Other difficulties, such as competing needs of other family members, are additional barriers to care.

The good news

On the positive side, "despite these stressors, supportive family and school characteristics have been shown to be associated with positive outcomes for children living in poverty," Witte said. Another key force is the community collaborative board—community members working together to design and implement services acceptable to the target population. As demonstrated by WIN for Asthma and MAYA, the involvement of community workers is critical to success. Witte emphasized that they must be engaged from the beginning of a project and incorporated completely into the fabric of the intervention. This type of community-based participatory research "is incredibly time-consuming and expensive, but the payoff is great because it shortens the time from efficacy to translation," she stressed.

Referring to the work of MacKay, Witte reiterated that "it takes a village—of youth, parent advocates, peers, clinicians, and services researchers"—to create a successful health behavior change program. Proof of the power of that approach are the outcomes from MacKay's HOPE (Homeless Outreach for Parents & Early Adolescents) family program and MFG (Multiple Family Groups for youth with disruptive behavioral difficulties). HOPE averaged more than 60% attendance over eight sessions among 72 homeless families, Witte said. MFG continued to draw an astonishing 80% of families at 16 weeks. STEP UP, a mental health intervention for adolescents, drew close to 70% attendance at 16 weeks. The national average for retention in such programs is less than 50%.

Echoing others, Witte emphasized that the take-home messages for ECC, are to take a collaborative stance with parents in the health promotion of their children; use a community collaborative board model for interventions; and when developing programs, take into consideration the multiple barriers that keep parents from collaborating successfully in their children's health promotion.

Engaging providers: Part two of the dyad

Changing demands of the health care system have led to public health messages that encourage patients to become partners in their own care, rather than simply acquiescing to prescriptions, recommendations, and advice from "expert" providers, such as physicians and dentists. Yet the newer models of care also present challenges because they create new roles and expectations for parents and providers, neither of whom may be as well prepared as they should be to take them on, explained Judith Albino of the University of Colorado, Denver.

Traditionally, providers used their knowledge and experience to deliver treatments and recommendations to compliant patients.

In Albino's work with Native Americans, who have "staggeringly high" rates of ECC, "we have no alternative but to do community-based participatory research," of the type described by McCord, Ramos, Witte, and others, she said. The community is currently unprepared to manage their care because they are not "health literate," a skill defined as the ability to obtain and understand basic health information and services needed to make appropriate health decisions. They are also subject to the social stresses described by Witte.

At the same time, for interventions to be successful in ECC across the board, dental care providers need to transition to new roles—something that is likely to be uncomfortable for many, she acknowledged. "Studies of dental provider characteristics show that they believe that they, rather than their patients or specific treatments, really make a difference in oral health outcomes," Albino explained. Control is the primary driver for professional satisfaction—and the greatest source of provider dissatisfaction is problem patients.

This mindset creates a paternalistic approach to patients that sustains the expertise/compliance model for dentist/patient interactions. "Implicit in this approach is that the role of the dentists is to provide expertise, and the role of the patient is to listen and comply," Albino said. "But research has repeatedly shown that knowledge cannot motivate or change behavior. The probability that parents will do what they're told just because they're told to do it is quite small." Nevertheless, she emphasized, dentists persist on spending time and money on things that will really make very little difference in what parents and children do.

Albino posed the question: "If interventions to promote the oral health of young children were designed by behavioral scientists—rather than by biological scientists or clinicians – what would they look like?" As the speakers before her emphasized, the key is to listen to what the parent is saying, and to listen for "context and meaning," not just words. Such an approach would enable dentists to better understand the many challenges faced by parents with disparities, including the need to build oral health literacy and feelings of self efficacy, and deal with real-life problems such as lack of money for gas to enable them to drive to the dentist's office.

Speakers:
Sebastian Bonner, New York Academy of Medicine
Susan Witte, Columbia University School of Social Work
Philip Weinstein, University of Washington

Highlights

• Social cognitive theory posits that human behavior is influenced by variables in environmental, personal, and behavioral domains; all must be attended to for an intervention to change behavior.
• A childhood asthma intervention based on social cognitive theory reduced the percentage of children who did not get inhaled corticosteroids from 89% to 38%.
• Social work theory takes an individualized, client-centered approach that emphasizes strengths, not deficits; the approach is effective and well suited for ECC prevention.
• The motivational interviewing technique is based on the idea that behavior change occurs only when the provider takes time to uncover the person's need to change, identifies the obstacles that cause ambivalence, and offers choices.

New framework for pediatric health interventions

Programs such as those described by Ramos and McCord are among the relatively few in pediatric health that embrace key theories and concepts from the social sciences that may be unfamiliar to clinicians. These theories, which underpin many successful programs dealing with addiction and behavior change, are now making their way into public health.

Social cognitive theory, developed by psychologist Albert Bandura in the 1950s, can be found in various guises in public health interventions. Sebastian Bonner of the New York Academy of Medicine explained the theory as follows: "All human functioning can be explained and predicted by variables in three domains—environmental (physical and social), personal (beliefs, perceptions, attributions, self-efficacy), and behavioral. Each domain is influenced by and influences the other two, a concept known as reciprocal determinism."

The main lesson for pediatric health is that all three domains must be attended to in any intervention that aims to change health behaviors. The environment, in particular, is often neglected, as standard approaches focus primarily on a person's beliefs, attitudes, and behaviors. But the environment is not a static thing that is just there in the background, Bonner stressed. "It's dynamic and part of the very fabric of human functioning."

Social cognitive theory can be used to address issues from sexual health to childhood asthma.

Bonner offered two examples of programs that essentially reshape the environment to improve health behaviors, demonstrating the versatility and applicability of social cognitive theory to health interventions. The first, Project DiSH (Diet and Sexual Health), aimed to reduce social isolation and HIV risk among black men who have sex with men. Multiple environmental, behavioral, and personal variables influence risky sexual behavior in this population.

The intervention was developed after Bonner saw analogies between healthy sex and healthy eating. DiSH promotes communication and socialization in a small group setting in which participants cook and share meals. "We've found it's a powerful way to demonstrate support and caring for oneself and others, and to create opportunities for the men to build friendships outside bars and clubs," Bonner said. "The focus is on nourishment and health, and building relationships that do not necessarily involve sex." Condoms and sexual risk-reduction information are also available.

A total of 300 men participated in a pilot randomized controlled trial. At the time of the presentation, approximately 7/8 of the sample had completed the trial and:

• 90% of participants attended at least 4 of the 5 biweekly sessions
• 92% of sessions had total expected attendance
• 96% of the expected 3-month follow-up visits were completed

Participation has been amazing even without the use of standard retention strategies, Bonner observed. The same principles may be used to create an environment conducive to promoting oral health in children.

Rethinking asthma care

The second intervention was a childhood asthma program that aimed to increase the use of inhaled corticosteroids and reduce the use of rescue albuterol, as recommended by national asthma management guidelines. Bonner observed that in neighborhoods such as Harlem, where the intervention was centered, children's asthma hospitalization rates are quadruple the national average. Using social cognitive theory, Bonner outlined the determinants of poor asthma control in day care:

Environmental factors

• Community norms focus on triggers and albuterol
• In day care centers, health service delivery is mandated, but child care and education are the primary foci
• There is haphazard identification of children with asthma and no standardized screening
• Day care centers have little power to affect provider behavior (i.e., whether or not inhaled corticosteroids are prescribed)

Personal factors (parents and day care staff)

• There is resistance to inhaled corticosteroids.
• Health beliefs are based on inaccurate understanding of asthma.

Behavioral factors (of parents and day care staff)

• Asthma is dealt with by restricting the child's behavior or by (often naïve) trigger-avoidance strategies.
• Sick children are provided with acute, episodic care rather than ongoing prevention.
• Caregivers rely on emergency departments for primary care.

Using inhaled steroids to control asthma is counterintuitive, Bonner explained. Inhaled steroids relieve inflammation and control symptoms over time, but they won't make a child feel better in the moment, which is what rescue albuterol does. But although albuterol may help a child breathe better acutely, it has no impact on the disease process. Parents also expend a lot of effort on reducing environmental triggers, such as dust and smoking, that will have no lasting impact on the disease unless the underlying inflammation is controlled.

"Our whole effort is to take the disease out of the environment and locate it in the lungs," Bonner said. He compared usual care by parents to a merry-go-round: the child has an asthma exacerbation; he's given albuterol, which provides quick relief; the symptoms return; he's given more and more albuterol, which masks the underlying disease; eventually, the child "crashes," goes to the emergency room, gets oral prednisone, and then he goes home and is back on the merry-go-round.

To get the child off the merry-go-round, the team tackled the environmental variables by trying to get staff in two day care centers to use an asthma detection instrument and to hold physicians accountable for following treatment guidelines. At the same time, they tried to help parents understand the course of the disease.

"It's not just about collaborating with the day care center; it's about having them change the way they do things and monitoring to ensure they do so. With respect to parents, we don't give them asthma 101; instead, we have nine modules that we use to personalize the disease, giving the message about inhaled corticosteroids in different ways, depending on how ready the parents are to hear the information."

With monitoring to ensure surveillance, the team was able to significantly reduce the percentage of children who did not get inhaled corticosteroids over a two-year period from 89% to 38%. The program is being rolled out in 180 day care centers in New York City, reaching about 18,000 children.

Social work theory: accentuate the positive

Susan Witte, Associate Director at the Social Intervention Group at the Columbia University School of Social Work, uses social work practice principles to inform and refine theory-based interventions that effectively change behavior. Witte and her colleagues develop, test, and disseminate risk-reduction interventions in the areas of HIV/STIs, drug abuse, intimate partner violence, and trauma. The tenets that underpin the interventions have relevance for ECC, Witte said.

The first tenet is starting where the client is. As McCord observed earlier, every client is different. "Cognitive theory becomes relevant when it is assumed that reality, whatever we call it, is not an objective fact, but rather is created in the mind of the individual by the way he or she perceives, thinks about, gives meaning to, and is otherwise conscious of experiences of living," Witte said. "This is relevant to improving pediatric health because if you can't engage a parent effectively, based on their perceptions, you have little chance of improving the child's health."

To promote change, the provider must collaborate with clients' aspirations, perceptions, and strengths.

The second tenet involves taking a "strengths" perspective, rather than an approach that identifies the client as having problems or pathology. This means acknowledging that, particularly in populations with disparities, "given all the difficulties people have, they're often doing amazingly well," Witte said. The emphasis is on capacities—will, vision, skills—that have allowed individuals to survive to this point, rather than on deficits and insufficiencies. This approach underscores that change requires that the provider collaborates with clients' aspirations, perceptions, and strengths, and firmly believes in them. For ECC interventions, this would include understanding parents' attitudes towards ECC, and why they may not see value in ECC prevention.

The third tenet emphasizes the importance of an ecological-systems approach, which researchers are already applying to children's oral health, Witte acknowledged.

In the early stages of developing ECC interventions, in addition to looking at specific strategies that have worked in other settings, "it's important to build in ways to look at mechanisms of change," Witte continued. Understanding these mechanisms will enable investigators to "measure what each component of the intervention may be achieving, as well as the skills that the facilitator is required to enact, enable or facilitate change. Only by understanding the mechanisms of interventions that have positive outcomes can effective programs be brought to scale, she explained.

In Witte's work in HIV prevention, "the number one key was facilitator engagement," she said. She suggested a number of characteristics of good facilitation:

• Joining: Starting where the client (the family unit, in the case of ECC) is and emphasize strengths
• Externalizing: Acknowledging that the person is not the problem (reducing stigma)
• Observer stance: Maintaining a neutral, observer role, bearing witness to change
• Positive reinforcement: Providing support, positive feedback in the face of stigma
• Harm reduction: Reducing expectations for outcomes; accepting that change will be incremental
• Intrafamilial communication: Asking whether other family members, such as grandparents, support the intervention
• Social support/network mapping: Drawing on the strengths of the community.

"Borrow from social work, from HIV prevention, from behavioral interventions and consider seriously at outset the contribution of the facilitator and his or her skills," Witte urged. "Aim to evoke strengths, and therefore capacity and commitment of the family to the intervention."

Motivational interviewing: self-assessment, choices

Philip Weinstein of the University of Washington's Department of Dental Health Services overturned several assumptions that underpin many ECC interventions. "We assume people are motivated to change, but the evidence says that 80% aren't really ready. We need to acknowledge this or our interventions will be ineffective." People also assume that giving information or advice—the "education" model—will be effective. But studies have shown that 30% to 60% of health information is quickly forgotten. "Moreover, while information may change how we think, it doesn't change how we act," Weinstein emphasized.

Motivational interviewing uncovers a person's need to change.

Rather, changing behavior involves a process wherein the provider uncovers the person's need to change; identifies the obstacles that cause ambivalence; and provides choices. This is the essence of motivational interviewing (MI), a form of brief counseling/cognitive-behavior therapy that has been shown to be effective with addiction since 1983, and is often used today in programs that aim to establish new health behaviors.

Underlying MI is a simple concept: People don't care what you know until they know you care. That feeling of caring and trust "must occur whether we're giving surgery, pill, or advice. The literature shows that if we don't have that piece in place, we have nothing," Weinstein explained. In addition to building trust, the work of Weinstein and others has shown that MI involves: asking questions and actually listening to the responses; providing advice and information only after trust has been established, not initially; emphasizing choices, not prescriptions.

How does MI for ECC work? Weinstein provided examples of the kinds of interactions that might take place at each juncture of the intervention.

To motivate the mother:

• Ask open-ended questions that show concern and encourage the mother to talk, such as:
  • "Tell me about your teeth (and the teeth of your family)"
  • "What difficulties have you had?"
  • "What do you want for your (child's) teeth?"
  • "Suppose you were granted a 'dental miracle.' What would happen?"

After the open-ended questions:

• Demonstrate empathy by using skillful "reflective listening"—reflecting back to the mother what she said, and interpreting the underlying meaning.
  • Simple reflection: Use the mother's words, then paraphrase: "It sounds like…"; summarize at intervals what the mother is saying.
  • Amplified reflection: Reflect with enthusiasm what the mother says.
  • Double-sided reflection: "On the one hand you…"
• Reflect ambivalence: "You seem to be telling me there are good things about (dental treatment) and some not so good things about it."

The antithesis of reflective listening include strategies such as giving advice, making suggestions, reassuring the mother, interrupting, changing the subject, or being judgmental.

Before introducing options for change, it's "critical" to talk with the mother about the pros and cons of the intervention/new behaviors. Instead of trying to coerce her into participating or changing, ask:

• "What are some good things about (taking your child to the dentist); what are some
  not so good things about it?"
• "What will be hard for you to do; what will the benefits be?"

Use reflective listening strategies rather than attempting to refute difficulties.

Finally, instead of offering solutions, clinicians who use the MI approach offer a "menu" of choices, from which the mother identifies up to three that she is willing to use, as well as the obstacles to using them.

Weinstein concluded by noting that almost every medical school in the United States teaches MI, but dentistry is "far behind." Only five dental schools teach the technique, despite the fact that its use has led to, among other results, a 50% reduction in new caries in young children over a two-year period compared to usual care.

Speakers:
Cheryl Austein Casnoff, Health Resources and Services Administration (HRSA)
Kathy O'Loughlin, United Healthcare Group

Highlights

• Barriers to health information technology (HIT) adoption for children's health include cost, fewer group pediatric practices, and lack of pediatrics-appropriate products for HIT.
• Electronic health records can change the balance of power between patients and providers.
• Concerns about privacy, security, and the status of the child complicate the HIT picture for children.
• Significant federal Recovery Act money will be earmarked for HIT.
• Payment and reimbursement strategies for preventive oral health interventions need to be revamped.
• Medicaid and other public programs account for less than 4% of the monies that go to dentists, despite the fact that children living in poverty account for 80% of dental disease.
• Doc Dent Link is a new program aimed at educating healthcare providers about the need to examine, refer, and provide preventive services such as fluoride varnish to children under age 5.

Healthcare IT: Key to access

Ideally, if a child is enrolled in a health promotion program for asthma, ECC, or another condition, he or she would also be receiving messages consistent with the program from other providers. But right now, that is rarely the case. "Children more than adults are touched by so many systems—schools, Head Start, day care, foster care, courts, and so forth—but no one is connecting the dots," said Cheryl Austein Casnoff of the Health Resources and Services Administration (HRSA).

As documented in a recent supplement in the journal Pediatrics, children's health has lagged behind other specialties in uptake of health information technology (HIT), specifically, electronic health records (EHRs), Casnoff said. Barriers to health information technology adoption children's health include cost, fewer group pediatric practices, and lack of pediatrics-appropriate products for health IT.

Electronic health records could help families track and coordinate their care.

But the adoption of EHRs could provide families with data about their children's health and assist them in tracking their children's health and development, effectively "changing the balance of control between patients and providers, and promoting self care," Casnoff observed. For children with special health care needs who receive services in both health and social services programs, personal health records (PHRs) could enable the exchange of information between agencies, supporting both records coordination and communication. "That would eliminate the need for parents to carry boxes of records from provider to provider for a child with multiple needs," Casnoff said.

It is important that parents receive the same health promotion messages wherever they go, so if everyone has the same information, then messages can easily be consistent. Moreover, right now, if a pediatrician refers a child to a dentist, the dentist will never know unless parent tells him or her; but if records are shared electronically, the referral goes through immediately.

Concerns about privacy, security, and the status of the child complicate the HIT picture for children. Questions arise over the definition of a minor, whether an adolescent should be allowed to see his own health record, and how to handle custody disputes. But these issues will eventually be straightened out, especially as the federal Recovery Act money becomes available to support these initiatives. Oral health providers need to talk with states [the recipients of Recovery Act funds] to make sure oral health is at the HIT table.

HRSA is developing an online toolkit related to children's health. Current module topics include: an introduction to children and HIT; developing pediatric-friendly emergency medical records; building a medical home for children; cross-sector coordination and planning for children's health; facilitating enrollment and retention in public health insurance programs using HIT; involving family members in their child's health care; improving quality with children's health IT; and advanced topics on leadership and organizational design. Casnoff encouraged oral health providers to contribute to the tool box by offering feedback on existing modules and helping to create a module on children's oral health (interested parties should e-mail Sophie Miller [miller-sophie@norc.org] or Chris Dymek [dymek-chris@norc.org]).

She concluded by summarizing recent policy recommendations from the National Oral Health Policy Center at Children's Dental Health Project:

• Extend current HIT and health care quality improvement programs to pediatric oral health.
• Include IT in new general and oral health programs for children.
• Establish a pediatric-specific demonstration program.
• Charge programs serving at-risk children, such as Head Start, to develop HIT linkages with pediatric medical and dental providers.

Financing ECC prevention: Who will pay?

Even if dentistry were incorporated into the fabric of HIT, that does not solve the problem of payment/reimbursement for preventive oral health care. The current system for financing children's dental services—especially preventive care—works best for those who tend to have the least dental problems: children whose families have enough money to pay out of pocket or for a dental insurance plan, and who value preventive oral health care.

The vast majority of dental care is paid for out-of-pocket or by private insurance plans.

Medicaid and other public programs serving children in need account for less than 4% of the monies that go to dentists—despite the fact that children living in poverty account for 80% of dental disease, said Kathy O'Loughlin, formerly of United Healthcare Group and now executive director of the American Dental Association. Two reasons account for the low percentage: public programs are grossly underfunded and pay a very small percentage of normal dental fees, and only about 20% of children with the Medicaid dental benefit actually see a dentist for care. Some states are working hard to drive that number up, but it is still low compared to the 75% of kids with private insurance that access dental care.

It will be difficult to bring successful pilot programs to scale without changing the mindset of policymakers as well as commercial payers (and, as noted by Albino, many dentists) to emphasize prevention/health promotion over treatment, O'Loughlin observed. Systems will need to change, as well, to provide:

• Fair/or higher payment for preventive/promotion services
• Incentives for health care professionals to promote prevention
• Incentives for people who participate in preventive services
• Risk assessment and disease management
• A level of health literacy of the beneficiary that encourages preventative health behaviors

Electronic health records and risk-assessment processes that are consistent among companies are also needed. "Currently, if five companies deliver benefits, we see five different processes to do so," O'Loughlin said. "Fewer than 50% of pediatric dentists have electronic health records, even though 78% of them send electronic claims."

As a step in the right direction, United Healthcare has initiated a fluoride varnish program aimed at primary care physicians and pediatricians. O'Loughlin acknowledged that, after listening to the other symposium presenters, she realized the program was not optimally developed to induce behavior change—that is, it was created without input from the community or with the idea that participating physicians might use motivational interviewing or other effective behavior-change strategies. However, she is optimistic that it can nonetheless promote the use of the preventive strategy.

Called Doc Dent Link, the program uses a Web-based tool to educate health care providers about the need to examine, refer, and provide preventive services such as fluoride varnish to children under age 5. The physician is reimbursed for screening, for applying fluoride to children at high risk, and for referring the child to a dentist. The program has the potential to be "economically viable" for pediatricians, O'Loughlin said, and the researchers are now capturing claim data to see if the program lowers dental costs.

"Just keeping children out of operating room gives us a big bang for the buck—probably a 45% savings for that alone," she observed. "A typical emergency department visit costs $6000 per episode and many children have multiple episodes, year after year."

Getting these types of preventive programs to scale will probably require involvement of the public health world to develop effective models, she acknowledged. "But once they're in place, commercial carriers will jump in to fund them, because intervening early is only way to make a difference" in health and in costs. "There is hope," she concluded.