OPENWIDE An Innovative Oral Health Program for Non-Dental Health and

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OPENWIDE An Innovative Oral Health Program for Non-Dental Health and Powered By Docstoc
					OPENWIDE: An Innovative Oral Health
Program for Non-Dental Health and Human
Services Providers
Stanton H. Wolfe, D.D.S., M.P.H.; Colleen E. Huebner, Ph.D., M.P.H.
Abstract: Emerging awareness of the nature and severity of oral diseases and disorders and their serious impact on overall health
and well-being, combined with a nationwide crisis in access to oral health care for populations with the most and worst disease,
makes it imperative that non-dental health and childcare professionals engage more fully in oral health promotion and disease
prevention. OPENWIDE is a comprehensive training program designed to help achieve this goal. The Connecticut Department of
Public Health has trained more than 2,000 individuals during the first year of the OPENWIDE program. This article reports on
successes and impediments to training and implementation encountered in the early stages of OPENWIDE and makes recommen-
dations to improve the curriculum and its delivery to families and children.
Dr. Wolfe is Associate Professor and Head, Division of Public Health and Community Services, Tufts University School of
Dental Medicine; Dr. Huebner is Associate Professor, Department of Health Services, School of Public Health and Community
Medicine, University of Washington. Direct correspondence and requests for reprints to Dr. Stanton H. Wolfe, Tufts University
School of Dental Medicine, Division of Public Health, Department of General Dentistry, One Kneeland Street, Boston, MA
02111; 617-636-3741 phone; 617-636-2965 fax; stanton.wolfe@tufts.edu.
Key words: medical providers, childcare providers, oral health promotion, oral disease prevention
Submitted for publication 2/6/04; accepted 3/1/04




R
         ecent research and policy reports have stimu-                    ease, and the impact of oral diseases and disor-
         lated a growing awareness of the nature and                      ders on children’s health and well-being;
         severity of diseases and disorders of the                   2.   Integrate oral health promotion and disease pre-
mouth and their serious implications for overall                          vention into existing health, education, and
health and well-being. Dental decay and periodonti-                       childcare systems;
tis are painful transmittable infectious diseases that               3.   Teach non-dental health, early childhood edu-
have been linked to low birth weight, cardiovascular                      cation, and childcare providers to recognize and
conditions, diabetes, poor nutrition, speech impair-                      understand oral diseases and conditions;
ments, and psychosocial problems.1-6 The public’s                    4.   Train non-dental providers to carry out activi-
lack of knowledge about oral health promotion and                         ties that promote oral health and prevent and re-
                                                                          duce oral disease, including oral screening, risk
limited access to pediatric dental services are sig-
                                                                          assessment, anticipatory guidance, and appro-
nificant impediments to oral health for infants and
                                                                          priate referral for restorative and other needed
toddlers, particularly for low-income and minority
                                                                          care; and
populations.1 To improve the oral health of young                    5.   Ultimately, make a positive impact on overall
children, it is imperative that “front-line” profession-                  health and well-being through improved and ex-
als—pediatricians, family practitioners, obstetrician-                    panded oral health promotion and early preven-
gynecologists, physicians assistants, nurse practitio-                    tion and intervention.
ners, Head Start coordinators, and other non-dental
health and childcare providers—join oral health pro-
viders to ensure that health promotion and disease
prevention efforts reach those in need.                              Oral Disease in Connecticut
       The OPENWIDE training program was devel-
                                                                           The Oral health Program to Engage Non-den-
oped and implemented in Connecticut to engage non-
                                                                     tal health and human service Workers in Integrated
dental professionals and paraprofessionals in oral
                                                                     Dental Education (OPENWIDE) is an oral health
health promotion and disease prevention.
                                                                     promotion and disease prevention education and
OPENWIDE is designed to achieve five goals:
                                                                     training program. OPENWIDE was designed in re-
1. Build awareness and knowledge of the impor-
                                                                     sponse to Connecticut’s oral health crisis. In Con-
     tance of oral health, the prevention of oral dis-
                                                                     necticut, early childhood caries (ECC) affects as

May 2004    ■   Journal of Dental Education                                                                                         513
      many as 25 percent of low-income inner-city minor-                 In the earliest years of life, more children are
      ity children ages three to five years. Among school-         seen by medical health providers than by any other
      age children, the estimate of dental decay prevalence        health, social, or education provider group. Yet, to
      is even higher. For instance, 57 percent of school           date, the majority of pediatric medical health pro-
      children surveyed by the Connecticut Department of           viders receive little or no education and training in
      Public Health (DPH) had experienced dental decay             the examination, health, and care of the mouth, and
      by age nine, and 40 percent of second grade school           hence are not likely to consider oral health as a high
      children had active untreated dental decay.7 In the          priority.13 Nevertheless, medical professionals are the
      year 2000-01, over 50 percent of children actively           frontline providers of health care for infants and chil-
      enrolled in the Connecticut Medicaid Managed Care            dren, including low-income and minority popula-
      program (called “HUSKY”) received no preventive              tions. Early childhood educators and daycare pro-
      or other dental treatment services.8 At the time of the      viders are in routine contact with large numbers of
      HUSKY survey, 740 of the 2,680 dentists licensed             young children as well. A program that motivates,
      in the state were registered as Medicaid providers,          educates, and enables health, education, and childcare
      but fewer than 10 percent (225 of 2,680) were “ac-           providers to integrate oral health promotion and dis-
      tive” Medicaid providers who provided any preven-            ease prevention into their day-to-day practices could
      tive or treatment services in 2001.9 In Connecticut,         help close the gap in prevention services, especially
      there are over sixty dental “safety net” facilities (den-    among high-risk, low-income children and help re-
      tal clinics in schools, community health centers, hos-       duce the prevalence of dental disease in future gen-
      pitals, free-standing health centers, mobile vans, etc.)     erations. OPENWIDE14 is such a program.
      that help fill the gap. However, the safety net facili-
      ties are located in only twenty-four of 169 cities and
      towns, leaving large regions of the state without any
      readily accessible dental care for underserved
                                                                   Program Description:
      populations.                                                 OPENWIDE
             Recently, the American Academy of Pediatric
      Dentistry recommended the first well-child visit to                The OPENWIDE curriculum was written and
      the dentist occur by age one year—younger than the           designed by the author (SHW) with considerable
      previous practice standard of three years of age.10 In       assistance from Pamela Painter, R.D.H., M.S.P.H.,
      reality, the dental workforce is insufficient to meet        of the Connecticut Department of Public Health.
      the needs of even the older children. It is estimated,       OPENWIDE was developed for practitioners includ-
      for example, that nearly a quarter million children          ing state agency professionals, physicians, medical
      ages three to eighteen years are dentally underserved        students and residents, nurses, nutritionists, Head
      in the state of Connecticut alone.9 The need for new         Start, childcare, and outreach workers, and others.
      approaches to protect infants’ and children’s oral           These providers at the frontline of health care are
      health is clear, but who can fill the need? Currently,       trained to address many other preventive, treatment,
      predoctoral dental education and training are weak           and maintenance health needs of the people and popu-
      regarding the examination and clinical care of very          lations they serve. OPENWIDE expands their scope
      young children.11,12 Many general dentists are uncom-        of practice by bringing the mouth back into the rest
      fortable seeing a child as a patient before three years      of the body.
      of age. Nationally and in Connecticut, there are too               The OPENWIDE curriculum teaches non-den-
      few pediatric dentists who are qualified and eager to        tal providers to:
      see this population, and they are inadequately dis-               1) Recognize and understand the implications
      tributed to meet the need. Training a new cohort of                  of oral diseases and conditions,
      dentists who are skilled, comfortable, and eager to               2) Recognize and address risk factors for oral
      treat infants and toddlers will require major changes                diseases and conditions,
      in dental school curricula and training, as well as a             3) Provide anticipatory guidance and prevention
      culture change among private dental providers. While                 interventions for oral health, and
      the dental treatment delivery systems for underserved             4) Make appropriate referrals for oral diagno-
      populations are being built, low-cost, easily                        sis, definitive treatment, and maintenance.
      implementable, and sustainable programs that em-                   Curriculum development began with a nation-
      phasize disease containment and prevention must be           wide literature and Internet search for health promo-
      instituted.                                                  tion and disease prevention programs that focus on

514                                                               Journal of Dental Education ■ Volume 68, Number 5
early childhood oral health education and training       of Public Health, Early Head Start/Head Start, Com-
for non-dental providers. The best elements of the       munity Health Centers, hospital pediatric and ob-gyn
programs that met these criteria, notably                residency programs, family medical practice meet-
Washington’s ABCD Program and Massachusetts’             ings, Yale University School of Medicine, Univer-
physician training program, were adopted and             sity of Connecticut (UConn) School of Medicine,
adapted for OPENWIDE with new material created           community childcare provider meetings, and more.
where needed. An advisory committee was convened         Training has taken the form of OPENWIDE lead
with representatives from state agencies, the Univer-    trainer trainings (“train the trainer”) as well as group
sity of Connecticut School of Dental Medicine, Con-      presentations. OPENWIDE lead trainers from around
necticut State Dental Association, Connecticut Oral      the state complete at least six hours of standardized
Health Initiative, Connecticut Dental Hygiene As-        training including how to organize and conduct
sociation, Connecticut Chapter of the American           OPENWIDE presentations. Lead trainers include
Academy of Pediatrics, physicians and allied medi-       DPH staff, community dentists and dental hygien-
cal health professionals, outreach and childcare or-     ists, physicians, nurses, outreach workers, childcare
ganizations including Head Start, foundations, and       professionals, Head Start workers, and educators. A
others. The advisory committee provided consider-        modified version of OPENWIDE was adapted for
able expert feedback in the development of               the Connecticut-Charts-a-Course, a training program
OPENWIDE’s content and training formats. In ad-          of the Child Health Development Institute, in-ser-
dition, a brief survey was mailed to 3,000 family        vice childcare educational program, with a constitu-
practice, pediatric, and ob-gyn physicians in Hart-      ency of nearly 3,000 childcare workers. In addition
ford County to gain a sense of their level of under-     to in-person trainings, the content of OPENWIDE
standing of the importance of oral health, their oral    has been adapted to new formats including an inno-
health knowledge base, their desire for continuing       vative, interactive case-study web-based program
education/training in oral health, and the training      created by UConn Health Center affiliates. The web
format to which they would be most amenable. Fo-         format has provided a way to integrate oral health
cus groups and field-testing provided additional feed-   education into the UConn predoctoral medical stu-
back.                                                    dent curriculum and into pediatric residency train-
       The result is a comprehensive multimedia          ing at UConn and at Yale.
modular education program, the components of                    One community health center in northeastern
which are summarized in Table 1. The modular na-         Connecticut illustrates how the training has been re-
ture of OPENWIDE allows for customization of pre-        ceived by dental and non-dental health profession-
sentations to meet the needs of specific audiences.      als. Nearly sixty individuals were in attendance for
OPENWIDE can be adapted readily for presentations        this two-hour OPENWIDE presentation, including
of forty-five minutes to a half-day in length. Con-      the executive director of the community health cen-
tent can range too, for example, from a focus on the     ter, clerk receptionists, physicians, dentists, nurses,
oral health of one- to three-year-old children, appro-   dental hygienists, dental assistants, radiology tech-
priate for childcare providers, to a discussion of the   nicians, and others—a very wide range of education
possible association between advanced periodontal        levels and health awareness and knowledge. Forty-
disease in the mother and delivery of a pre-term low     four of the employees completed a self-report sur-
birth weight infant, appropriate for ob-gyn residents.   vey distributed to all attendees. Thirty-one usable
                                                         surveys were returned and entered for analysis of
                                                         post-training knowledge.
Field Tests of OPENWIDE                                         The self-report survey (available upon request)
                                                         included attendee demographic information, six true/
Provider Trainings and Effects                           false questions that measured oral health awareness
                                                         and knowledge pre- and post-presentation, and ques-
on Provider Knowledge                                    tions about the quality of the OPENWIDE material
                                                         and presentation. The six oral health awareness and
       Since its inception in 2002, OPENWIDE has         knowledge true/false test questions covered such ar-
been very well received by the professional commu-       eas as the prevalence, nature, and impact of tooth
nity. Training programs have been provided to nearly     decay, dietary habits and tooth decay, and oral hy-
2,000 individuals from the Connecticut Department        giene in early childhood.


May 2004   ■   Journal of Dental Education                                                                          515
            Thirty-one participants handed in the surveys,             both the pre- and post-test were analyzed. The pre-
      but not all completed both the pre- and post-test for            test mean was apparently 52 percent (47/90) for cor-
      all questions. The aggregate total of ninety aware-              rectly answered questions, and the post-test mean was
      ness/knowledge questions that were completed for                 67 percent (61/90). All participants’ answers that were


      Table 1. OPENWIDE program components and contents
        Components           Contents                                                        Comments

        Full-Color Binder    • 3” 3-ring, with custom pockets for CD-Rom, 2 VCRs,
                               quick reference fact sheets and clinical guides,
                               brochures, and slide guides
                             • Full-color section dividers

        Curriculum           70-page modular curriculum with sections on:
                             • Dental Decay                                                  Each module begins with
                             • Early Childhood Caries                                        written teaching objectives and
                             • Risk Factors for Dental Decay                                 trainer-training guidelines and
                             • Prevention of Dental Decay                                    protocols.
                             • Anticipatory Guidance
                             • What to Do and How to Do It

        Reference Guides     14 pages (front-back), full-color laminated
                             8” x 10” guides for:                                            Joined together by a ring clasp
                             • Anticipatory Guidance                                         intended for hanging on wall in
                             • Risk Assessment                                               work area for quick reference.
                             • Tooth Identification and Eruption
                             • Clinical identification of:
                                   Normal Dentition
                                   Dental Decay
                                   Early Childhood Caries
                                   Dental Developmental Defects
                                   Dental Sealants

        CD-Rom               • 45-minute Early Childhood Caries PowerPoint                   The General Resource Slides
                               presentation, in English and in Spanish                       can be used to customize
                             • 50+ General Resource Slides, in English and Spanish           presentations for different
                             • Oral Screening Labels file                                    audiences.

        VCR                  • Baby Teeth: Love ‘Em and Lose ‘Em, in English and Spanish     An educational and oral health
                                                                                             promotional short video suitable
                                                                                             for waiting rooms, parents
                                                                                             meetings, etc. (created by the
                                                                                             University of Washington).

        Appendices           • Educational brochure selected samples
                             • Ordering information for educational brochures
                             • Contact information
                                  Safety-net dental providers
                                  HUSKY (Connecticut children’s CMS program)
                             • Directory of towns with fluoridated water systems
                               (Connecticut)
                             • Directory of public water supply systems (Connecticut)
                             • Presentation scripts and slide-guides for PowerPoint
                               presentations, in English and in Spanish

        Radio/TV Spots       • 4 60-second TV spots, targeting early childhood and
                               adolescent oral health promotion, in English and Spanish
                             • 4 30-second radio spots, targeting early childhood and
                               adolescent oral health promotion, in English and Spanish

        Website Postings     • Connecticut Department of Public Health:
                               www.dph.state.ct.us
                             • University of Connecticut School of Medicine:
                               www.uchc.edu
                               Core Curriculum Series:
                               http://155.37.7.13/corehtml/coremain.htm




516                                                                  Journal of Dental Education ■ Volume 68, Number 5
correct at pre-test were correct again at post-test; no           priate for our audience . . . the speaker kept the audi-
participant changed from a correct to an incorrect                ence interested . . . entertaining and very easy to fol-
response. The question that showed the least im-                  low but not too basic.”
provement in awareness/knowledge from pre- to                            When asked “how could the training program
post-test asked about the appropriate age to begin                be improved?,” responses included: “include teen-
brushing an infant’s/toddler’s teeth, suggesting the              agers, soda and rampant decay . . . seemed repetitive
curriculum needs to be strengthened in this regard.               a lot . . . us giving you more time for more in-depth
       Responses to Likert-scale questions about sat-             topics.” Although the training presentation was ap-
isfaction with the OPENWIDE presentation appear                   proximately two hours in length, several participants
in Table 2. The overall rating was “excellent”; qual-             said they would have liked a longer, expanded
ity of speakers and materials received the highest                presentation.
ratings. Three-quarters of the participants (76 per-
cent) agreed the training provided new useful skills
and information, and 69 percent agreed training
would lead them to increase oral health promotion
                                                                  Effect on Practice Change
in their daily routines. Three open-ended questions                     Early Head Start and Head Start (EHS/HS) are
elicited additional, more specific information. When              nationwide federally funded programs serving low-
asked “what new oral health promotion and disease                 income pregnant women and children birth to three
prevention activities would respondents routinely                 and three to five years of age, respectively. Recently
include in their daily activities?,” respondents wrote:           the Connecticut Department of Public Health com-
“all, especially importance of fluoride at 6 mos . . .            pleted OPENWIDE training for all twenty-eight
screening for caries . . . physical screening . . . assess        EHS/HS sites in the state. The training programs
oral health during immunization administration . . .              consisted of 1.75-hour in-person presentations to
early referral to dentist for preventative [sic] care . .         EHS/HS managers, family coordinators, or health
. anticipatory guidance-assessment . . . letting people           educators. These programs provided an opportunity
know that baby teeth are important . . . discussing               to examine the extent to which OPENWIDE effec-
effect of parent’s dental health on their children . . .          tively reached staff to raise their understanding and
give patients information about dental services [the              knowledge of oral health, and strengthen their focus
Community Health Center] provides.”                               on children’s oral health in day-to-day EHS/HS
       Responses to the question “what were the best              operations.
things about the training?” included: “[presenters’]                    To examine the impact of training on practice,
style and slides . . . clearly presented . . . excellent          telephone interviews were conducted two to six
slides . . . very interesting and explanatory . . . speak-        months after the EHS/HS trainings. The intended
ers spoke at a ‘level’ that was not too clinical so we            individuals to be contacted by telephone included
[non-health professionals] could understand . . . en-             one health manager, one family service coordinator,
tertaining and engaging presentation . . . very appro-            and one teacher from each of the twenty-eight



Table 2. Community health center staffs’ satisfaction with the OPENWIDE presentation
                                                     Percent of Respondents Choosing Score: (n=44)
MEASURE                                                                 SCORE
                                       1                 2                 3                 4                 5
                                Not at all/Poor                                                        Completely/Excellent
Overall rating                                                                                            >99 percent
Quality of speakers                                                    1 percent         17 percent       82 percent
Quality of slides,
handouts, etc.                                                         3 percent         24 percent        73 percent
Gained new useful skills
and information                                                       24 percent         16 percent        60 percent
Will increase oral health
promotion in daily routine        1 percent          3 percent        27 percent         27 percent        42 percent




May 2004    ■   Journal of Dental Education                                                                                   517
      Connecticut EHS/HS sites (eighty-four people total).                  Health, and Sarah Freilich, a student research assis-
      Individuals were chosen from each site’s personnel                    tant, conducted all interviews and entered all re-
      rosters at random; they need not have attended the                    sponses, additional discussions, and comments made
      training to be interviewed. The purpose of including                  by the respondents. The telephone interviews were
      EHS/HS personnel who had not attended the train-                      approximately fifteen to twenty minutes in length.
      ing was to learn whether OPENWIDE training at the                     Data entry and analysis were completed using the
      program level led to diffusion within sites of oral                   Statistical Program for the Social Sciences (SPSS,
      health promotion and disease prevention knowledge                     version 11.0).
      and materials to enhance the existing oral health cur-                      Forty-seven of the eighty-four individuals se-
      riculum. A scripted interview (available from author)                 lected for the interviews completed them. Although
      included twenty-three questions with items cover-                     the response rate was low (56 percent), interviewees
      ing the following: respondent demographics; whether                   represented twenty-six of the twenty-eight Connecti-
      they had attended an OPENWIDE presentation; per-                      cut EHS/HS agencies and all counties in the state
      ceived importance and prioritization of oral health                   (Table 3). All respondents were female; the majority
      for their clients; whether oral health education, an-                 were white and had completed four years of college.
      ticipatory guidance, and prevention were being inte-                  Among the individual respondents, thirteen attended
      grated at their sites; and perceived obstacles to                     OPENWIDE training (27 percent), and 42 percent
      strengthening the oral health component of their                      reported they had the OPENWIDE manual and re-
      EHS/HS program. Interviewees who had attended                         lated material at their EHS/HS sites.
      OPENWIDE trainings and those who had                                         In the telephone survey, the majority of respon-
      OPENWIDE materials at their sites were asked an                       dents answered the knowledge-based oral health sur-
      additional set of questions concerning the usefulness                 vey questions correctly, including questions about
      of the OPENWIDE resource materials and informa-                       the correct amount of toothpaste to use and the role
      tion. Interviews were conducted by telephone to in-                   of sugar in the pathogenesis of dental decay. How-
      crease the response rate and minimize disruption to                   ever, tests of association to determine if correct re-
      EHS/HS personnel. Pamela Painter, R.D.H.,                             sponses were more likely among OPENWIDE train-
      M.S.P.H., of the Connecticut Department of Public                     ing participants showed no statistically significant


      Table 3. EHS/HS telephone survey: sample characteristics (n = 47)
                                        Goal        Actual      Response rate     Number           Number            Number who
                                                  number of       (percent)     female/male      who attended          have OW
                                                 respondents                                     OW training       manual/components

      EHS/HS sites                      28            26            92.8
      Professional Role
       Health Managers                  28            24            85.7          24 / 0
       Family Service Coordinators      28            15            53.5          15 / 0
       Teachers                         28             8            28.6           8/0
      Total Staff                       84            47            55.9          47 / 0      13 (27.6 percent)    20 (42.5 percent)
      Race/Ethnicity*
       White                                          34
       Black, African American                        8
       Hispanic, Latino                               4
       Other                                          2
      Educational Attainment
       4 years college                                31
       2 years of college                             9
       Some college                                   4
       High school                                    3

      *
        Participants could indicate more than one category for Race/Ethnicity; hence, there are 48 total responses for Race/Ethnicity
      as compared to 47 for Total Staff.




518                                                                        Journal of Dental Education ■ Volume 68, Number 5
association with attendance. That is, respondents who      sheets were most likely to be used; 45 percent of
attended OPENWIDE did not have significantly               respondents who had the manual at their site said
more oral health knowledge than others at their sites.     they used these materials at least once.
Chi-square tests were completed for each of the                  Interviewees were asked to comment on chal-
knowledge questions; the test statistic ranged from        lenges to increasing a focus on oral health in day-to-
1.19 to 1.81 (χ2 [1, n = 47] = 1.19 to 1.81, p > .05).     day operations, in educating staff, and in educating
The source of respondents’ oral health knowledge           parents about children’s oral health. Fifty-eight per-
base (or lack thereof) was not determined.                 cent of the forty-seven participants explained that it
       All respondents indicated it was “very impor-       was difficult to educate parents about oral health
tant” for them to actively promote good oral health        because of parents’ personal health beliefs and pri-
to clients, and the large majority (85 percent) believed   orities; parents’ lack of interest, follow-through, and
that it was “very important” for them to actively pro-     time; and language barriers that exist between par-
vide guidance to clients on how to prevent dental          ents and HS staff. Only 19 percent of the forty-seven
disease. These responses were consistent with the          respondents commented that EHS/HS programs
perception voiced by the majority (71 percent) that        lacked the time, staff, or financial resources to add
the EHS/HS client population is at high risk for den-      oral health education to their present curriculum and
tal decay. Sixty-five percent of respondents reported      responsibilities, and 13 percent stated there were no
oral health promotion and disease prevention educa-        obstacles.
tion in the EHS/HS setting is necessary. The most
common two oral health promotion objectives were:
finding a dentist for their clients (44 percent) and
tooth brushing in the classroom (27 percent).
                                                           Discussion and Conclusions
       To assess the degree to which oral health pro-            OPENWIDE is a new program designed to
motion materials and activities were in practice at        enhance oral health promotion, prevent oral diseases
the EHS/HS sites, respondents were asked how many          and disorders among children, and increase their ac-
parent-staff meetings took place at their site in the      cess to oral health care by educating and motivating
past six months and, out of those meetings, how many       non-dental health, education, and childcare profes-
of them included information about oral health. Since      sionals to bring the mouth back into the rest of the
the forty-seven respondents represented twenty-six         body. By engaging frontline health and childcare
sites and since no more than three individuals (and        providers, potentially many thousands of underserved
most commonly one or two) could be from any one            children and caregivers can benefit from oral health
site, the individuals can be considered to represent       screenings, disease prevention, anticipatory guid-
the sites relatively closely as well. Seventy-nine per-    ance, and appropriate referral for treatment services.
cent of individual respondents indicated that they had     Since publication only eighteen months ago, but with
four or more parent-staff meetings in the past six         lessons learned from numerous training programs,
months, yet the majority (60 percent) stated that oral     OPENWIDE is under scrutiny and revision. It is a
health was not included as a topic at any of the meet-     dynamic program, and its methods and materials are
ings. Only 40 percent reported that one or more of         edited, expanded, and otherwise modified as de-
the meetings did include oral health as a topic of dis-    manded by experience, new knowledge, and peri-
cussion. Frequency tests of association revealed that      odic evaluations.
people who attended OPENWIDE trainings were not                  Findings from the evaluation efforts described
significantly more likely to include oral health as a      here are being used to guide modifications and en-
topic at meetings with parents (χ2 [1, n = 45] = 1.49,     hancements of OPENWIDE and to guide develop-
p > .05).                                                  ment of new modules on Adolescent Oral Health (in-
       Integration of OPENWIDE’s oral health ma-           cluding injury prevention, nutrition/obesity, tobacco
terials into day-to-day practice at the EHS/HS sites       use prevention) and Oral Health for the Mature Adult
was also assessed by asking about usage of the             (including oral cancer prevention and early detec-
OPENWIDE manual and its components. Of those               tion). A more rigorous longer-term evaluation
who had materials on site, the majority said they did      planned for the future will provide evidence-based
not use most of the materials. Among the compo-            insight into whether OPENWIDE is a model of “best
nent parts, OPENWIDE reference cards and fact              practice” and, more importantly, whether



May 2004    ■   Journal of Dental Education                                                                          519
      OPENWIDE can have a positive impact on promot-                ing of providers about how to improve communica-
      ing oral health and preventing oral disease.                  tion with parents and motivate them to become more
             The study of pre- to post-changes in knowl-            active in ensuring their children’s oral health.
      edge and satisfaction reported here revealed an over-                In the meantime, with the importance of oral
      whelmingly positive response to the OPENWIDE                  health to overall health inarguable, there is a press-
      goals, curriculum, slides, supplemental resources,            ing need that frontline non-dental health and childcare
      and presentation. Opinions gathered in the EHS/HS             providers integrate oral health promotion and dis-
      study confirmed these views, but also revealed the            ease prevention into the mix of their day-to-day prac-
      intended practice changes were not happening: not             tices. The OPENWIDE program, content, curricu-
      even the OPENWIDE manual or resource materials                lum, resource materials, implementation process,
      were in common use. There appeared to be no dif-              and, perhaps most importantly, its inherent flexibil-
      ferences between individuals who attended                     ity and adaptability make it an excellent resource for
      OPENWIDE presentations and those who did not in               working toward this vision.
      terms of their knowledge of oral health, integration
      of oral health activities in program practices, or uti-
      lization of OPENWIDE material and resources. Al-
      though disappointing, there are several limitations
                                                                    Lessons Learned
      to the study that temper these findings. The relatively              We make the following recommendations to
      small sample size and disproportionate response rates         build on OPENWIDE’s success and address its weak-
      among the different EHS/HS professional staff (i.e.,          nesses. Hopefully, these recommendations will as-
      relatively few teachers participated in the telephone         sist other groups that are implementing, or planning
      interviews) are two limitations. Additionally, numer-         to implement, similar oral health education and train-
      ous concurrent oral health promotion and disease              ing programs.
      prevention programs are ongoing in CT. As a result,           1. Additional process evaluation is needed to gain
      it was not possible to control for diffusion effects of            greater understanding of the impediments to day-
      other sources of oral health information to the pro-               to-day implementation of OPENWIDE. Future
      fessional community (specifically to the health man-               efforts might employ case studies of successful
      agers) or the community at large.                                  and less successful sites and focus groups with
             Limitations beyond study design must be                     providers and with parents. These evaluations
      considered as well. Nearly 20 percent of the EHS/                  should focus not only on the characteristics and
      HS professionals reported not having enough fund-                  issues of the target non-dental providers, but also
      ing, not enough staff, and not enough time to intro-               on the social, cultural, and behavioral charac-
      duce a new program. Additionally, more than half                   teristics and issues of the providers’ client popu-
      the EHS/HS respondents surveyed identified “par-                   lation.
      ents” as a primary obstacle to improving oral health          2. OPENWIDE training should be scheduled on a
      practices within the program. When queried further,                repeating cycle to reinforce the principles and
      they cited parents’ lack of interest, unavailability, lack         goals of the program and offset threats to imple-
      of concern regarding oral health, and the like. Al-                mentation due to provider turnover and family
                                                                         mobility.
      though this is anecdotal information and may reflect
                                                                    3. OPENWIDE should be implemented as part of
      reporting bias born of frustration, the frequency and
                                                                         a comprehensive oral health promotion and dis-
      consistency of the reports indicate this should not be
                                                                         ease prevention social marketing program to help
      ignored. In retrospect, it is likely that parent input in          change provider and client attitudes toward,
      the development of OPENWIDE was not sufficient                     prioritization of, and health behaviors with re-
      and that further revisions of OPENWIDE should                      spect to oral health.
      focus on both its content and delivery mechanisms.            4. As OPENWIDE implementation is improved
      For instance, focus groups with parents would be                   and expanded, a rigorous longitudinal evalua-
      valuable to inform the OPENWIDE content and print                  tion of health outcomes should be developed and
      messages. To improve program delivery,                             implemented. Ultimately, the real measure of
      OPENWIDE trainings could be strengthened further                   programs like OPENWIDE is whether or not
      with information about behavioral change, parent                   they are making a positive impact on individu-
      education, cultural competency, and explicit train-                als’ and communities’ health and well-being.



520                                                                Journal of Dental Education ■ Volume 68, Number 5
                                                                  6. Offenbacher S, Katz V, Fertik G, et al. Periodontal infec-
Acknowledgments                                                       tion as a possible risk factor for preterm low birth weight.
      We would like to acknowledge and thank the                      J Periodontal 1996;67(10 Suppl):1103-13.
State of Connecticut Department of Public Health                  7. Wolfe SH. Connecticut oral health survey and needs as-
                                                                      sessment of second grade school children. Hartford: Con-
and all the members of the OPENWIDE Advisory
                                                                      necticut Department of Public Health, 1997, unpublished
Committee for their support and hard work in the                      report.
development, implementation, and evaluation of this               8. Annual report. Hartford: Connecticut Department of So-
innovative educational and training program. The                      cial Services, Children’s Health Council, 2002.
OPENWIDE Program was made possible through                        9. Wolfe SH. Present and projected dental provider partici-
funding from the Robert and Margaret Patricelli Fam-                  pation in the Connecticut Medicaid managed care pro-
                                                                      gram: impact on oral health care access. Hartford:
ily Foundation, Connecticut Health Foundation, and                    Connecticut Department of Public Health, December
Connecticut Department of Public Health.                              1996, unpublished report.
                                                                  10. 2003-04 policies and guidelines: guidelines on periodic-
                                                                      ity of examination, preventive dental services, anticipa-
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May 2004     ■   Journal of Dental Education                                                                                         521