blogs.ubc.cablogs.ubc.ca/pkaljanac/files/2011/11/Community-Repor… · Web viewThis coverage includes services such as exams, x-rays, fillings, cleanings and extractions.14 Emergency

Vancouver Coastal Health – Richmond

A Community Externship Children’s Dental Screening Program

DHYG 310

November 30, 2010

Professor Diana Lin

Priscilla Kaljanac

Natasha Lee

Doris Lok

Rubyjean Banzon

TABLE OF CONTENTS

Executive Summary 2

Recommendations 3

Assessment and Diagnosis 4

Program Plan 6

Implementation 7

Evaluation 8

Appendices 10

Appendix A – Situational Analysis 11

Appendix B1 – Kindergarten Dental Health Survey Data 17

Appendix B2 – Client Profile 19

Appendix B3 – Caries status for health service areas within Vancouver 20

Appendix B4 – Low Cost Clinics 21

Appendix B5 – Richmond Dental Survey Results 22

Appendix B6 – VCH Services 23

Appendix B7 – VCH Richmond Services 24

Appendix B8 – Support Systems 25

Appendix B9 – Healthy Kids Benefit 26

Appendix C1 – Program Planning 27

Appendix C2 – Resources/Budget 28

Appendix C3 – Work Plan Timeline and Roles 30

Appendix C4 – Implementation Activities 32

Appendix D – Checklists 34

Appendix E – Caries Risk Assessment 44

Appendix F – Photographs 45

Appendix G – Resources: Pre-reading Material and Research 46

Appendix H – Team Reflections 48

Appendix I – Post Assessment 55

Appendix J –References 56

Appendix K – Articles for Situational Analysis 58

1

EXECUTIVE SUMMARY

The following community externship report details the work of four UBC dental hygiene

students who participated in a Children Dental Health Screening program at the Richmond, BC

division of Vancouver Coastal Health. The program, which is headed by community dental

hygienist Ms. Lisa Enns, provides oral screening and fluoride varnish for children aged six and

under who are at high caries risk, and provides oral health education to their parents. For

populations at higher levels of risk exposure, such as Richmond, the goal of this public health

program is to facilitate change and improve health by focusing on and improving the

individual’s role in the change process, focusing on care over cure, and addressing the four

principle elements affecting health: biology, environment, lifestyle and health care

organizations. 1 Detailed herein is the implementation of a plan to aid facilitation of this fluoride

varnish program. The implementation spanned four weeks, with students seeing four to six

families over a period of three hours each week. Assessment and diagnosis of the target

population was based on census data from Statistics Canada and Vancouver Coastal Health.

Objectives were created in concurrence with VCH dental health program and in coordination

with Ms. Enns. Common issues encountered among clients concerned nutrition and oral health

status. A take-home checklist was provided to reinforce and help maintain the information

learned. Although the majority of caregivers were compliant, the expected outcomes varied

among families according to their readiness to embrace change.

2

RECOMMENDATIONS

1. Ensure all members have done thorough research in the area of child development.

2. Ensure that every opportunity is taken to receive feedback and ask questions of site personnel, whose knowledge and experience are invaluable resources.

3. Each member must be well prepared for any pre-implementation orientation or practice sessions with site personnel in order to benefit most from the experience.

4. Professionalism is important during implementation, specifically when members are representing Vancouver Coastal Health (VCH) and University of British Columbia to the public. One must have done thorough research and be knowledgeable to ensure the proper advice and information is given at all times.

5. Creation of a work plan with timeline will help in planning, coordinating group members, and ensuring that activities are completed on time.

6. Create specific roles with responsibilities for each group member during planning and implementation.

7. Be aware of time constraints. For example, during implementation one member may conduct the interview while the other documents – this allows for greater efficiency and more detailed charting.

8. Organization is the key. Have a basic plan of action and follow it. Have all materials organized and at hand.

9. Be assertive and take a leadership role to ensure that both the child’s caregiver and hygienist mentor has confidence in clinician’s skills and advice.

10. Prior knowledge and training in Motivational Interviewing is an invaluable skill to have when advocating change in caregivers.

11. Previous experience in child behavioural management may be helpful in overcoming children behavioural issues.

12. Use of visuals such as Early Childhood Caries illustrations would be an effective prevention tool to raise caries awareness in parents who would be otherwise unable to recognize them.

13. Many relevant brochures are available from VCH, and it may be worthwhile to distribute them to reinforce and help maintain the information learned during the appointment. However one must take care not to overwhelm caregiver with information.

14. If the budget permits, a laminated or more visually attractive or colourful checklist may increase the likelihood of use.

15. Ensure there is thorough documentation of all activities, assessments and services performed to ensure proper evaluation of program effectiveness.

3

ASSESSMENT AND DIAGNOSIS OF TARGET GROUP

Community Context:

Richmond’s Vancouver Coastal Health (VCH) clinic is conveniently located in the city

centre, surrounded by restaurants, banks, malls, and small shops. It is also very close to

Richmond City Hall, Brighouse Library, Richmond High School, Minoru Park, Richmond

Hospital, and the Canada line station. Richmond is a multicultural community with a 57.4%

immigrant population. 2 63% of the population is a visible minority, predominantly Chinese and

making up 47% of the city’s entire population. 2 The population of children is low with 15.5%

under age 15. 2 Richmond has a high employment rate and high level of education, with an

average income of $59,569 among households with children. 2 Comparisons of a VCH survey

data over the past four years show that in 2010, 6% more children have never experienced tooth

decay; 1.2% more children have experienced dental restoration; and 7.3% fewer children had

visible tooth decay. 3 (Please see Appendix B5).

Characteristics of target group

TODDLERS:

Promotional materials are sent to caregivers when children are approximately 17 months

old. The program focuses on toddlers aged 2 and under, but is open to high risk children aged 6

and under without dental insurance who are found during daycare/preschool screenings.

Toddlers are at a moderate to high caries risk due to their dependence on their caregiver to

provide oral and overall care. 4 Toddlers do not have the dexterity to brush or floss their own

teeth, and uncooperative behaviour such as crying or biting often discourages parents from

completing a thorough cleaning of their child’s teeth. 5 Diet is dependent on caregivers who are

often unaware of the detrimental effect that certain foods, and the prolonged used of bottles and

sippy cups have on their child’s oral health. 6 Toddlers who are uncooperative in dental settings

may not be able to receive thorough oral care if parents cannot control their behaviour and dental

professionals are unable to perform services adequately. 7 Many toddlers have visible

4

minority/immigrant parents whose language issues may limit their access to oral care.

Community assessment is ongoing, and individual assessment at time of screening will

determine specific services to be performed.

CAREGIVERS:

Parents typically range in age from their 20s to late 30s, and are eager to learn oral

hygiene skills for their child, but program facilitators are unsure whether instructions are

followed at home. Caregivers often lack knowledge of the detrimental effects of prolonged

bottle/sippy cup use such as increased acid attack and teeth erosion due to prolonged exposure

from frequent milk/juice and sugar intake, and the importance of primary teeth to proper adult

tooth development. Due to limited English language skills, many caregivers will be unable to

comprehend English resources, and may require the use of a translator.

Community Diagnosis

Caregiver’s lack of knowledge on the prevention of dental caries leads to high caries risk

in their children. Some toddlers will have white or brown lesions due to demineralization,

indicating caries development. Caregivers are unaware of proper oral hygiene care for toddlers

and will require instruction on safe and proper brush/toothpaste use and brushing methods, and

the importance of a routine care regimen. Caregivers are unaware that certain foods (solids and

liquids), mode of delivery, frequency and quantity of food have an impact on their child’s oral

health. Caregivers need to be advised on fluoride toothpaste use and the benefits of fluoride

varnish application. Parents who bring children to the clinic indicate a willingness to learn and

make positive changes towards their child’s oral health. Some in the large Chinese demographic

may be unable to read English materials, indicating a need for visual aids and Chinese language

translations, and care must be taken to address the cultural diversity of oral health perceptions.

5

PROGRAM PLAN

Health promotion is “the process of enabling people to increase control over, and to

improve, their health.” 8 Appropriately, the promotion strategies focus on “Enable”,

“Advocate”, and “Mediate.” 8 Targeting Richmond children, whose locus of control is with the

caregivers, the program is about oral health prevention, early intervention, and promotion. The

aim is for parents to “develop personal skill” 8 in taking care of their children by teaching them

oral health instructions with the rationale that keeping good oral health is important, and to

encourage them to ask questions. The program also provides a supportive environment with

patient recalls and referrals to other recommended services.

At orientation meetings, Ms. Enns provided information of the established program, and

expectations of the externship. Implementation would encompass three parts: caries risk

assessment, counselling, and fluoride application. A checklist was given to help parents keep

track of recommendations made. Necessary dental resources were provided by Ms. Enns in

prepared ready to use boxes.

With Lisa’s vision for the program in mind, preparation went underway. Pre-

implementation largely consisted of research to support counselling and education. Main topics

include nutrition, oral health instructions, early childhood caries with respect to vertical and

horizontal transfer of bacteria, and access to oral health services (Appendix G). To be consistent

with VCH’s protocols regarding oral health counselling, various educational media provided by

BCDA and VCH were reviewed. Research on child behaviour management was conducted to

facilitate compliance, and on effective teaching strategies for caregiver instruction. Caries risk

assessment would be done concurrently with counselling in the format of Motivational

Interviewing (MI) as recommended and applied in Miss Enn’s mock interviews and professional

demonstrations. MI “helps uncover motivation” and leads parents from the precontemplative to

contemplative stage. 9 Fluoride varnish application will be applied to all high-risk children given

that there are no known allergies.

6

A checklist was proposed to highlight the specific needs and actions of the child and the

actions parents should take to improve their child’s oral health, while taking into account the

parent’s literacy skills. 10 Due to the Richmond demographics comprised being largely of

Chinese immigrants 2, a Chinese version was considered, depending on the background

assessment from the first two implementations. In addition, Doris, a team member and a mother

of a two-year old living in Richmond, also provided feedback on the checklist from a parent

perspective. Recall observations or follow-up calls were to be done to evaluate compliance and

effectiveness of the checklists.

(Please refer to Appendix C1 for further detail of plan, and Appendix C2 and C3 for

resource/budget information and timeline.)

IMPLEMENTATION

Appointments were conducted in one room during the four days of implementation.

They were booked at 30min intervals, and averaged 5 clients per visit. Each appointment was

led by two student hygienists, and supervised by Ms. Enns, who stepped in with her expertise

when appropriate. Feedback from Ms. Enns informed modifications to future appointments.

Each appointment was conducted as follows (Appendix C4):

1. Introduction to parents and raise question of chief concern to build rapport.

2. Brief medical history, including a family history of caries involvement.

3. Caries risk assessment

4. Advise and instruction on diet and nutrition.

5. Assessment of teeth and gingiva in the knee-to-knee position with parent.

6. Application of fluoride varnish.

7. Referrals were made to a dentist or to VCH nutritionist if needed.

8. Appointments ended by presenting parents with an oral health checklist, and briefly

outlining its use in accordance with the topics and issues discussed.

7

During some appointments, members took turns conducting each aspect of the

appointment. Unfortunately this method did not allow one to build upon the rapport already in

place with the first member who conducted the initial interview and assessments. The better

format was one in which the experienced member took the lead, while the new member played a

support role, such as taking notes and charting, which allowed for a smoother, more streamlined

experience for the team and the client.

The group contributed to the program with the creation of an oral health checklist, which

was given to the parents at the end of each appointment. The checklist contained reminders of

the main topics of concern and actions one should take to improve their child’s oral health.

Multiple versions were created, and one was selected and modified according to advice from

Ms. Enns. A Chinese language version was later made to cater to Chinese-speaking families,

who form the majority of clients. This checklist forms the basis for evaluation (Appendix

D). Follow-up calls to families from the third and last implementation, informed to the efficacy

of the checklist in inducing positive change in the actions of parents and the health of their

children.

EVALUATION

The program was successful in identifying children who are at high risk of dental caries

through the caries assessment process. Oral screening and fluoride varnish applications were

completed as planned on all children. From the interviews, observations of recalls and ongoing

assessment of the toddlers’ oral care were made, and prominent issues such as nutrition

management, oral care aid use and techniques, were identified. Accordingly, the checklist went

under several revisions.

The Motivational Interviewing technique seemed useful in building rapport with parents.

However, perhaps due to little awareness in oral health, most parents did not seem to have any

initial chief concerns for us to develop on. As a result, the interview format was conducted in a

modified MI technique, in which we asked open-ended questions and emphasized on praising

8

and encouraging the parents. The “menu” was in form of a checklist at the end of the

appointment. 9

Finalization of the checklists was towards the last two implementations, which were

summatively evaluated through follow-up calls. Some calls were conversed in Chinese, which

helped with the flow and effectiveness of the conversation. The Chinese version was deemed

helpful to parents during follow-up calls, in terms of breaking down English literacy issues. The

checklist provided at each appointment was welcomed by the majority of parents, who indicated

that it helped them to remember and maintain the given oral health recommendations. Most

parents made at least some changes, and only a small amount of parents followed all

recommended changes, and this may be due to the short window of time between visits and their

evaluation, being one to two weeks. Moreover, in conjunction to counseling, the checklist’s

effectiveness depended on factors such as the parents’ receptiveness to change, individual child

care strategies, and overall health literacy.11 Some may not have had the time, for example, to

find a dentist. Based on data collected from recall families and contacted families, it appeared

that the caregiver’s ability to make change was hindered by the toddler’s low cooperation, such

as brushing their child’s teeth with constant struggle. This was discouraging to some parents

who were not able to make immediate changes. However, changes recommended for older

children, age 3 and up, were more effective. (See Appendix I)

In working with each other, the students developed team dynamics as they gained more

experience. On future implementations, students must improve management of children

behaviour in order to facilitate the timely completion of oral screenings and fluoride varnish

applications.

9

APPENDICES

10

APPENDIX A – SITUATIONAL ANALYSIS

Strength of their situation (internal/individual) in terms of oral health and quality of life

There is a 61% health literacy rate in Richmond, BC. 2 The employment rate and average

household income is relatively high, with only 20.9% earning a low income after tax. 2 The

education levels are high with 14,345 out of 20,680 of population between 25-34 with post

secondary education. 2 With this background, Richmond parents may be more motivated to

further their knowledge in oral health, and to provide a healthier life for their children. 10

Their access to this dental health program is an action that demonstrates their awareness, and

is a step to improve quality of oral health. The young children that come, ages 0-6, usually

under 2, are still developing primary teeth. This is a strength for early intervention.

Assessing the screening programs, these babies can benefit from the early caries detection

and prevention education. Based on Vancouver Coastal Health’s surveys, the decay of

Richmond toddlers have been improving over the years. 3 (Appendix B1 Table i).

Weaknesses of their situation (internal/individual) in terms of oral health and quality of life

Richmond has the largest proportion of visible minorities and has the highest

proportion of immigrants in Canada in 2006 2 (See Appendix B2). From 2001-2006, 18,780

in Richmond had immigrant status. 2 Out of 173,565 Richmond residents, 105,250 of them

speak languages other than English. 2 This reveals the diverse culture and lifestyle among

Richmond families, as well as language barriers that affect delivery of oral hygiene

instruction and education. This hinders awareness on the following: oral care regimen for

babies or toddlers; proper nutrition for children from both dental and overall health stand

point; and the opportunities such as the BC Healthy Kids program. The differences in health

beliefs also become an issue. For some cultures, extraction is believed to be the best solution

11

for caries and that primary teeth are insignificant because they are deciduous. Other

limitations include managing temper of toddlers during oral hygiene care and their fondness

for sweets. Caregivers become reluctant to continue when a child cries during tooth brushing

and they tend to calm down kids with sweets. 11 A toddler’s dependency on their caregivers

for oral health care poses as a weakness too. Depending on the caregiver’s personal health

practices and health literacy, toddlers may be at risk for bad oral health. As reflected in

2009-2010 survey, 3 Richmond has the highest rate of visible decay within BC and the

highest rate of non-urgent referrals. 3 Compared to other Vancouver Coastal Health clinics,

Richmond division exhibited to be at higher risk of caries. It has highest percentage of

children with visible decay; highest percentage of urgent needs on day of screening; highest

percentage of children with no visible decay and restorations are present. 3 (Appendix B1

Table ii and B3)

Opportunities to maintain and improve their oral health and quality of life (external of

individual).

Residents of Richmond, BC : Vancouver Coastal Health (VCH) is Richmond’s public

health authority, and Richmond Health Services is a Provincial Government Agency under

them. 4 Richmond residents also have access to the services offered by VCH in Vancouver,

North Shore, Sunshine Coast, Bella Bella, Bella Coola, Central Coast, and the Sea-to-Sky

Highway. 5 VCH’s objective is to promote wellness and ensure care while supporting

healthy lives in communities through care, education, and research 5 (See Appendix B6 for

their health care services). Richmond immigrants may also apply for the Interim Federal

Health Benefit Program. 12 This program includes restorations, radiographs, exams, denture

placements, drug prescriptions, and anaesthetics. Scaling and root planning are not

12

included. 12

Clients of Vancouver Coastal Health (Location: 8100 Granville Ave., Richmond, BC ):

VCH’s services differ in each location (See Appendix B7 for health services). The Public

Health Dental Services program at this location is a prevention clinic which offers a ‘knee to

knee’ program to children age 3 and under. 6 This service is operated by a Registered Dental

Hygienist who checks for signs of tooth decay; provide fluoride varnish and education;

provide oral hygiene instructions; and give nutritional advice to the caregivers. 6 Varnish

programs are successful in terms of prevention. 7 In terms of promoting oral health with

babies and children outside the clinic, it is part of the VCH Registered Nurses’ role when

they educate caregivers in the community. (See Appendix B8)

Richmond toddlers with risk of caries: Besides the prevention clinic, other public dental

health services that Richmond children with risk of caries can access include the BC Healthy

Kids Benefit program. Families on BC Medical premium assistance are eligible for this

program. Children, until age 19, are eligible for $1400 of basic dental services every 2

years13 (See Appendix B9 for details). Families who are not on this assistance program can

bring their children to low cost dental clinics in the Greater Vancouver area (See Appendix

B4 for list). The Richmond Public Library has collaborated with Richmond Health Services

on a project to increase access to medical and health information. 11 This will help promote

health literacy among residents in Richmond. In particular, with the collection of oral health

resources at the library through books/DVDs/Internet, caregivers of toddlers with risk of

caries can supplement their oral health knowledge. Dental screening at schools was

mandated in 2012. 3 This is advantageous to our target group when they are in school,

especially for those whose parents still have not taken them to see a dentist. There are also

13

other funding such as ActNow BC. (See Appendix B8) This demonstrates that inter-

professional collaboration among private practitioners, public health officials and anyone

else who interacts with young children is very crucial in diminishing the prevalence of Early

Childhood Caries.14

Threats and challenges to their oral health and quality of life (external of individual)

The current capital funding for community dental clinics is about $1.2M. 3 However,

Richmond Health Department’s prevention program is the only clinic operating in

Richmond. Currently, there is no treatment component in the Richmond region. 3 When the

demand of access exceeds supply in the prevention program, some caregivers of toddlers

with caries risk may not receive crucial oral health education. These caregivers would be

less equipped to prevent potential caries and periodontal disease in toddlers early on, nor

would they receive necessary referrals to dentists. Also, many low-income parents have not

heard about Healthy Kids Benefit, due to inadequate advertisement. Not aware of dental

financial assistance programs or low cost clinics available, Richmond caregivers may forego

dental visits for their toddlers due to affordability, especially in economic recession. Limited

dental offices accepting toddlers and Healthy Kids Benefit can discourage parents from

pursuing further. With insufficient oral education in adults, caregivers may not even be

aware the need for early oral care. These children may be vulnerable to eating problems,

speech problems, embarrassment from caries, and problems with growth of permanent

teeth.15

Identify gaps in and problems with current oral health services for your target population

Toddlers are dependent on their caregivers when it comes to oral hygiene and proper

nutrition. Caregivers who visit the dentist regularly would have some knowledge of oral

health and oral disease prevention. Those who do not have this privilege would impact the

14

toddlers’ oral health in the long run. The lack of regular dental visits could be due to

families not having dental insurance, especially since it is not government funded. Also, the

lack of awareness of prevention can be the result of weak promotion of public health

opportunities, hence not reaching sufficient target population. An example is the lack of

communication to those on Medical Services Premium Assistance that they are eligible for a

dental benefit. For Richmond residents, VCH only offers a ‘knee to knee’ prevention clinic,

unlike Vancouver’s dental clinic where dentists provide restorative treatments.

Identify practicable/workable and sustainable activities and programs that are most likely to improve your target population’s oral and health and quality of life

Bring awareness to caregivers of the BC Healthy Kids Benefit and the low cost clinics available to them. With interprofessional assistance, caregivers can be notified of this by their family physician (whom they will definitely visit for children’s immunization), pharmacist, or community nurse (who visits them when the baby is born).

Expand the VCH dental public services offered to Vancouver residents to the Richmond residents. There is probably not enough resources to expand the Richmond clinic but it may be possible to open up the Vancouver locations to Richmond residents.

The VCH community nurses offer scheduled classes for caregivers on how to take care of their babies and toddlers (inclusive of an oral health care class). These classes are optional but if the curriculum was changed to compulsory, caregivers would not run the risk of missing the oral health care class.

Improve advocacy efforts for water fluoridation 16

Improve access to oral health services by reducing barriers (lack of access to dental care, community education, compliance with referrals) 16

Conclusion

Based on the analysis of the target population it is evident that Richmond has strengths

and weaknesses that affect their oral health status and quality of life. Strengths include

decreasing trends of tooth decay in children and increasing trends of higher education of

people living in Richmond. Weaknesses consist of language barriers preventing health

literacy of caregivers and higher risk of caries of children in the lower mainland, especially

15

in Richmond. However, many opportunities exist that can improve the target population’s

oral health status and overall health by implementing prevention strategies that are

accessible to everybody and by increasing awareness about the importance of prevention in

oral health. If these opportunities are not taken advantage of, the community’s health will

be compromised.

16

APPENDIX B

APPENDIX B1 – Table i: DENTAL HEALTH SURVEY OF KINDERGARTEN 3

Kindergarten Dental Survey - Overall Status 2006-2010

2005/06 2006/07 2007/08 2008/09 2009/10

Percent screened 92.04 92.06 94.44 93.04 93.47

Total No Visible Decay Experience 49.51 50.98 54.45 55.38 57.15

Total No Visible Decay - Restored 19.41 19.48 20.18 22.03 20.7

Total Visible Decay 31.08 29.53 25.38 23.22 22.15

Total Visible Decay One Quad 9.92 9.37 5.81 7.97 6.66

Total Visible Decay Two Quad 11.53 10.73 12.72 10.28 9.95

Total Visible Decay Three Quad 4.43 4.55 2.8 2.8 2.77

Total Visible Decay Four Quad 5.2 4.89 4.04 2.17 2.77

Total Urgent Need 2.53 3.73 3.15 2.1 2.04

17

APPENDIX B1 – Table ii: DENTAL HEALTH SURVEY OF KINDERGARTEN 3

Kindergarten 2009-2010: Compares the dental health of three regions under VCH. Note that Richmond has yet to meet the provincial target of 60% children with “No Visible Decay Experience”, and over 20% with “Visible Decay.”14

School Kindergarten Statistics Date Range: 2009-2010 Vancouver Richmond Coastal VCH Totals Number enrolled 4400 1626 2590 8616Total Number Screened 3918 1520 2426 7864 Total No Visible Decay Experience 2347 868 1908 5123 No Visible Decay Experience, Urgent 2 1 1 4Total No Visible Decay - Restored 777 315 344 1436 No Visible Decay - Restored, Urgent 15 6 2 23Total Visible Decay One Quad 203 101 72 376 Visible Decay One Quad, Urgent 4 4 2 10Total Visible Decay Two Quad 377 151 64 592 Visible Decay Two Quad, Urgent 11 6 1 18Total Visible Decay Three Quad 97 42 21 160 Visible Decay Three Quad, Urgent 9 5 1 15Total Visible Decay Four Quad 117 43 17 177 Visible Decay Four Quad, Urgent 17 9 3 29Total Visible Decay (1 - 4 quadrants) 794 337 174 1305

Total Non-urgent Referrals 753 313 167 1233Total Urgent Referrals 58 31 10 99Total Referrals 811 344 177 1332 Percents Percent Screened 89.05% 93.48% 93.67% 91.27%Total "No Visible Decay Experience*" 59.90% 57.11% 78.65% 65.14% No visible decay experience, Urgent 0.05% 0.07% 0.04% 0.05%Total No Visible Decay-Restored 19.83% 20.72% 14.18% 18.26% No Visible Decay-Restored, Urgent 0.38% 0.39% 0.08% 0.29%Total Visible Decay One Quad 5.18% 6.64% 2.97% 4.78% Visible Decay One Quad, Urgent 0.10% 0.26% 0.08% 0.13%Total Visible Decay Two Quad 9.62% 9.93% 2.64% 7.53% Visible Decay Two Quad, Urgent 0.28% 0.39% 0.04% 0.23%Total Visible Decay Three Quad 2.48% 2.76% 0.87% 2.03% Visible Decay Three Quad, Urgent 0.23% 0.33% 0.04% 0.19%

18

Total Visible Decay Four Quad 2.99% 2.83% 0.70% 2.25% Visible Decay Four Quad, Urgent 0.43% 0.59% 0.12% 0.37%Total Visible Decay 20.27% 22.17% 7.17% 16.59%

Total Non-urgent Referrals 19.22% 20.59% 6.88% 15.68%Total Urgent Referrals 1.48% 2.04% 0.41% 1.26%Total Referrals 20.70% 22.63% 7.30% 16.94% % "No Visible Decay Experience" 59.90% 57.11% 78.65% 65.14%% Visible Decay 20.27% 22.17% 7.17% 16.59%Total Number Screened 3918 1520 2426 7864Total Visible Decay (1 - 4 quadrants) 794 337 174 1305

19

APPENDIX B2 – CLIENT PROFILE

Target group: Children under age of 6 in Richmond, BC, through reaching out to their caregivers.

Richmond, BC community profile based on Stats Canada - An estimate of 185,400 (as of January 1, 2007) (corrects for undercount). - There are 50,225 census families - 84.5 % of the population are 15 years old and over.- Average Life Span in Richmond= 83 years old- Richmond have the lowest smoking and obesity rates- Out of the population of 173,565, 105,250 speak languages other than English- From 2001-2006, there are 18,780 who have immigrants status - 57.4% of the population were immigrants in 2006, the highest proportion of any municipality in Canada.

Visible minority (2006 report) Chinese: 75,725 South Asian: 13,860 Filipino: 9,555 Japanese: 3,230 Not a visible minority: 60,610

Educational attainment of population aged 25 - 34 years (total= 20,680) High school certificate or equivalent: 4,145 College, CEGEP or other non-university certificate or diploma: 3,755 University certificate or diploma below the bachelor level: 1,950 University certificate, diploma or degree : 8,640

Population in labour force Employed: 87,175 Unemployed: 5,290

Median after-tax income in 2005 - Couple households with children ($)59,569 Median income of Persons 15 years and over ($) 20,516 % of population with low income before tax - All persons 26.1 % in low income after tax - All persons 20.9 % in low income before tax - Persons less than 18 years of age 31.4 % in low income after tax - Persons less than 18 years of age 26.0

20

APPENDIX B3 – Caries status for health service areas within Vancouver

21

APPENDIX B4 – Low Cost Clinics 6

UBC’s Dental Treatment Clinico Eligible for low-income families in the Lower Mainland who are not eligible for existing government-funded programs.o Free one time treatment for children ages 6-12 by UBC dental students.o Offered during the academic year at either the UBC Dental Clinic or at their satellite dental clinic at Douglas College in New Westminster.

Douglas College Certified Dental Assisting Schoolo Eligible for clients age 4-25 for $20.o Includes exam by a dentist and tooth polishing, fluoride treatment, radiographs, and scaling by a dental assisting student.

VCC Dental Assisting Programo Prevention program for ages 4 – 21

Vancouver Community Dental Health Program – North Community Health Office Dental Clinico Basic dental services with reduced fees.

Strathcona Community Dental Clinico Basic dental services with reduced fees.

Reach Centre Dental Clinico Complete dental services with reduced fees.

Mid Main Community Health Centre Dental Clinico Complete dental services with reduced fees.

BC Children’s Dentistryo Eligible for children age 48 months and under with severe caries. Also, eligible for under age 17 with a significantly compromising medical condition such as cancer, organ transplant, congenital heart disease, cleft lip and/or palate, craniofacial anomaly, physical disabilities, medically diagnosed behaviour management issues such as developmental delay or autism.o Services include comprehensive, preventative, therapeutic oral health diagnosis, treatment, and consultation.

BC Children’s Emergency Dental Serviceso Children with acute dental pain/infection can be taken to the hospital’s emergency department if they are not able to go to a private clinic.

22

APPENDIX B5 – Richmond Dental Survey Results

23

APPENDIX B6 – VCH services

Primary health care at Vancouver Coastal Health includes care and treatment (i.e. medical and outpatient clinics), illness prevention (i.e. mental health and addiction services), health promotion (i.e. prenatal care and senior activity groups), community living supportive, and chronic disease management services.5 Their acute care includes surgical, medical, and psychiatric care in hospitals for children and adults. Their community care includes residential, home care, and home support services. 5 In addition, VCH helps protect from environmental health risks through food safety, water quality, air quality, pest management, sanitation, noise control, injury prevention, and tobacco reduction programs. 5

24

APPENDIX B7 – VCH Richmond services

This particular VCH branch in Richmond offers the following health programs to Richmond residents who access their services here: Adult Day Program, Air Quality Program, Audiology Services, BC Early Hearing Program, Child and Youth Immunization Program, Community Care Facilities Licensing, Community Nutrition Program, Drinking Water Safety, Early Childhood Vision Screening, Food Safety Program, Healthiest Babies Possible Program, Healthy Babies and Families, Immunization Clinics, Influenza Vaccinations, Recreational Water Safety, Safe and Healthy Environments, Speech and Language Services (children 0 – 5 yrs), Tobacco Reduction Program, Transitions, Vancouver Coastal Health Travel Clinic, West Nile Virus Program, Youth Clinics, and Public Health Dental Services. 5

25

APPENDIX B8 – Support Systems 3

School nurse dental support systems:

Video and discussion (primary grades) Dental bingo (intermediate grades) Sip smart! BC (intermediate grades)

Government support:Act Now BC – Financial support and collaboration with BC Dental Association on Early Childhood Caries prevention program.

26

APPENDIX B9 – Healthy Kids Benefit This coverage includes services such as exams, x-rays, fillings, cleanings and extractions.14

Emergency dental treatment (for immediate pain relief only) is also available if the child’s biennial limit has been reached. 14 Besides the dental benefit, there is an optical benefit that enables children to obtain prescription eyeglasses (lenses and basic frames) once in a twelve-month period. 14 Children’s eye examinations are already covered by BC Medical Services Plan.

27

APPENDIX C

APPENDIX C1 – PROGRAM PLANNING

Mission Statement: To improve the oral health of toddlers in Richmond.

Goal: To decrease incidence of ECC in toddlers through prevention and intervention with the Fluoride Varnish program.

Objectives:

1. To educate parents on nutrition and caries.a. To discourage ‘sugary’ (all fermentable carbohydrates) foods, sticky foods,

and frequent snacking. – EDUCATIONb. To encourage a decrease in prolonged usage of sippy cups/nipple, and

increase in early usage of cups (when toddler can sit straight-reference from DVD)-EDUCATION

2. To promote fluoride usage.3. To provide rationale of Fluoride varnish programs to decrease ECC on a brochure. –

EDUCATIONa. Fluoridated toothpaste – For kids with decreased amount. Fluoride’s benefit

in right amount – EDUCATIONb. To apply fluoride varnish for children – DIRECT SERVICE

4. To assist parents in home oral self care strategies with the toddlers.5. To demonstrate brushing techniques with a model – EDUCATION

a. To discourage mouth to mouth contact or horizontal transfer of bacteria, by explaining consequences of such action in relations to change in cariogenic oral flora. – EDUCATION

b. Pregnancy: To raise awareness in regards to correlation between Oral Self Care in pregnancy and babies’ potential ECC (vertical transfer) –EDUCATION

c. To provide oral hygiene instructions through usage of checklist -EDUCATION

6. To educate on effects of ECC.7. Handout brochures – Made by VCH: What it looks like; explain causes,

physiological affects of ECC on child (learning, speech, sleeping, etc), how it affects overall health and permanent teeth – EDUCATION.

a. Plaque buildup: also leads to gingival disease (raising awareness of possible outcomes). – EDUCATION

28

APPENDIX C2 – RESOURCES/BUDGET

Most resources provided by Vancouver Coastal Health (CDA approved fluoridated toothpaste for kids, kids toothbrushes, model for demonstration, bibs, fluoride varnish, disposable mirrors, pick floss, bottled water, disposable cups, stickers, loupe light, tissue, and brochure on oral health & nutrition).

Item EstimatedPrice x 1

Estimated Quantity

Estimated Projected cost

Amount Spent by Externship Students

Kids fluoridated toothpaste

$ 2.00 25 $30.00 $0.00

Fluoride varnish -white varnish 5%

$0.03 25 $0.75 $0.00

Kids toothbrush $3.00 25 $75.00 $0.00

Box of gloves $10.00 2 $20.00 $0.00

Disposable mirror $2.00 25 $50.00 $0.00

Floss pick $0.03 25 $0.75 $0.00

Disposable cups $0.03 30 $0.90 $0.00

Box of Tongue depressor

$4.00 1 $4.00 $0.00

Dental LED headlights $150.00 1 $150.00 $0.00

Hand held flash light $5.00 1 $5.00 $0.00

Give away stickers (roll)

$5.00 1 $5.00 $0.00

Dental models $150.00 1 $150.00 $0.00

Bibs $0.05 25 $ 1.25 $0.00

Gauze pack $10.00 1 $10.00 $0.00

Cavi Wipe pack $15.00 1 $15.00 $0.00

29

Printing costs $0.10 25 $2.50 $0.00

Checklist paper $0.20 25 $0.50 $0.00

TOTAL PROJECTED COST= $520.65

TOTAL AMOUNT SPENT=$ 0.00

30

APPENDIX C3 – WORK PLAN TIMELINE AND ROLES

Implementation was to be done in pairs due to room restrictions. One family was seen at a time. Under Lisa’s supervision, students partnered up and switched roles in terms of doing caries risk assessment or screening, and at times alternated after seeing each client.To facilitate improvements to the next visit, we decided the schedule so that one person from the previous visit could transfer her knowledge to the next visit, and in theory, lead the next person in the subsequent visit.

October 2010

M T W T F S S

27 - Submit proposed plan/outline

28 29 - Seek faculty opinion.

1 2 3

4 5 6 - Work on Situational Analysis.

7 8 - Lesson plan/topics completed.

9 10

11 12 13 14 15 16 - Compile brochure materials.

17

18 19 20 - Meet up with Lisa/faculty to orient and discuss pre-readings.Update our topics, observations/questions, activities, diagnosis, based on first visit.Submit checklist for faculty review.

21 22 23 24

25 26 27- Mock caries assessment and counselling with Lisa. - Show Lisa draft of checklist. - Re-submit checklist (if changes made) to Prof Lin for approval.

28 29 30 31

31

November 2010

M T W T F S S

1 2 3- PK and DL implement. - At the end of each day, do day evaluation with Lisa. - Notes on implementation.- Email newly revised plan to Prof Lin.

4 5 6 7

8 9 10- PK and RB implement. At the end of each day, do day evaluation with Lisa.- Notes on implementation.- Email newly revised plan to Prof Lin.

11 12 13 14

15 16 17- NL and RB implement. - At the end of each day, do day evaluation with Lisa.- Notes on implementation. - Email newly revised plan to Prof Lin.

18 19 20 21

22 23 24- NL and DK implement.

- At the end of each day, do day evaluation with Lisa.- Notes on implementation.- Ask Lisa to fill out form. - Pictures

25- Draft of Report, bibliography, - recommen-dations due.

26- Begin revision of report and editing of peer work.

27 28- Put report together. - Title page & table of contents.

29- Call parents for evaluation. - Practice presentation

30- Submit report Nov 30, 2010.

1- Peer evaluation

32

APPENDIX C4 – IMPLEMENTATION ACTIVITIES

1. Introduction to parents and raise question of chief concern to build rapport

We would ask the parents if they had any specific issues regarding their child’s oral health that they wanted to discuss first.

2. Brief medical history, including a family history of caries involvement.

We would ask if the child had any problems at birth such as preterm or low birth weight. We would also ask if the child has any medical conditions or allergies to bandages or sunscreen. We would explain that there is an ingredient (called wood resin) in bandages and sunscreen that is also in the fluoride varnish. If the child was allergic to those applications, we would not be able to put varnish on.

3. Caries risk assessment

We would cover all the questions on the caries risk assessment form provided by VCH to determine whether the child was low risk, moderate risk, or high risk. We would focus on whether there was a history of family tooth decay; if the child is bottle-fed or breast-fed; what type of snacks the child has and the frequency; if the child has seen a dentist yet; and if there were problems with brushing the child’s teeth. We would explain their implications and give them some suggestions if it is not in the best interest of the child or we would applaud them for doing a great job if what they were doing was contributing to good oral health.

4. Advice and instruction on diet and nutrition.

We would give them nutritional counselling in terms of oral health, but limited counselling for overall health. Essentially we follow the Canada Food Guide for the latter.

5. Assessment of teeth and gingiva in the knee-to-knee position with parent.

We would hold the child in a position where the clinician’s knees are touching the parent’s knees with the child lying down with his/her head on the clinician’s lap. We would look at the gingiva and teeth with a mirror and light. Then we would brush the child’s teeth to remove plaque; test for gingivitis; and demonstrate to the parent on how to brush properly. We would also use the dentoform to illustrate the proper technique if demonstration on the child was not successful. If applicable, we would also teach wiping of gingiva or flossing with a floss pick. If the parent will not have help when brushing their child’s teeth, we would teach them the floor position.

6. Application of fluoride varnish.

We would wipe the child’s teeth with gauze to dry it then brush on the fluoride varnish. This is done fairly quickly before the child loses patience. We would sit the

33

child up and give the child some water to drink so the varnish would dry and adhere. We would give the child a sticker to keep him/her happy.

7. Referrals were made to a dentist or to Vancouver Coastal Health’s nutritionist if needed.

For further nutritional counselling, we would refer them to the Nutritionist at VCH. If their child has not seen a dentist yet and the child was age 1 or older, we would refer them to a list of low cost dental clinics or to look into BC Healthy Kids.

8. Appointments ended by presenting parents with an oral health checklist, and briefly outlining its use in accordance with the topics and issues discussed during the appointment.

We would give the parent any additional advice while presenting them with a checklist that they can use as a reminder of the topics and issues discussed during the appointment. We would check off certain points on the list so the parent would put extra focus on them when they tend to the child’s teeth.

34

APPENDIX D – CHECKLISTS

Orientation Draft #1:

Richmond Health DepartmentDental Program8100 Granville Avenue(604)233-3216

Tips from your Public Health Dental Hygienist

Toothpasteo Use fluoridated toothpaste

Age 0-3 yrs: grain size amount Age 3+ yrs: use pea size amount

Brushing for child (till Gr. 3) o Lift the lipso Use toothbrush with soft bristles and small heado Angle the brush to tooth @ 45˚o Brush all surfaces of all teeth- don’t forget the back side and the rear teeth!

Dieto Eat/drink less carbohydrates (sugars) o Decrease snacking o Do not share food/drinks with childo Give water between meals, not juice

Dentist Appointmento First checkup: 1 year old

Additional items o Flosso Brushing technique: in the same order, but roll brush out

__________________’s next Fluoride Varnish application is booked on ____________ @ ______ .

If you must change this time, please contact the Dental Health Program at (604)233-3216.

For information on low cost dental clinics: http://www.bcdental.org/Find_a_Dentist/ReducedCostClinics.aspxHelpful links:

35

http://www.bcdental.org/Find_a_Dentist/ReducedCostClinics.aspx



Tips from your Public Health Dental Hygienist Fluoridated toothpaste

o Age 0-3: use rice size; age 3+: use pea size

Brushing for child (till Gr. 3) o Lift the lipo Use small, soft bristleso Angle the brush to tooth @ 45˚o Brush all surfaces of all teeth- don’t forget the back side and the rear teeth!

Dieto ↓Eat/drink carbohydrates (sugars). See Canada’s Food Guideo ↓Frequencyo ↓Share nothing with your saliva in ito Give water between meals, not juice

Full Check-upo First checkup: 1years old

Advanced: o Flosso Brush: in the same order, roll brush out

_________________’s Next Fluoride Varnish Appointment:_________________ @_______


For information on lower cost dental clinics: http://www.bcdental.org/Find_a_Dentist/ReducedCostClinics.aspx Helpful links:

36




_________________’s Next Fluoride Varnish Appointment:_________________ @_______


For information on lower cost dental clinics: http://www.bcdental.org/Find_a_Dentist/ReducedCostClinics.aspx

37



38

Implementation 1 (November 3, 2010):

39

Implementation 2 (November 10, 2010):

40

Implementation 3 – English Version (November 17, 2010):

41

Implementation 3 – Chinese Version (November 17, 2010):

42

Implementation 4 – Final English Version (November 24, 2010):

43

Implementation 4 – Final Chinese Version (November 24, 2010):

44

APPENDIX E – CARIES RISK ASSESSMENT

45

APPENDIX F – PHOTOGRAPHS

46

APPENDIX G – RESOURCES: Pre-reading Material and Research:

Motivational Interviewing

Weinstein P, Harrison R, Benton T. Motivating parents to prevent caries in their young children. J Am Dent Assoc. 2004;135:731-8.

Harrison R, Veronneau J, Leroux B. Design and implementation of a dental caries prevention trial in remote Canadian Aboriginal communities. Trials [serial on the Internet]. (2010), [cited November 30, 2010]; 1154. Available from: MEDLINE with Full Text.

Orientation package for VCH externship

Student practice education [Internet]. Vancouver Coastal Health; 2010 [updated 2010 Sep; cited 2010 Nov 29]. Available from http://studentpractice.vch.ca

Vancouver Coastal Health. Preventing early childhood tooth decay [DVD]. British Columbia: Vancouver Coastal Health; 2006.

British Columbia Dental Public Health Committee. Provincial fluoride varnish program protocol 2009. BC (Canada): British Columbia Dental Public Health Committee; 2009.

Human Early Learning Partnership. Analysis & Mapping of the 2006/07 British Columbia Kindergarten dental survey. BC (Canada): University of British Columbia; 2009.

Vancouver Coastal Health. Prevention of tooth decay in children 0-5 years: anticipatory oral health advice. BC (Canada): Vancouver Coastal Health; 2010.

Vancouver Coastal Health. Recognizing tooth decay in 0-5 years. BC (Canada): Vancouver Coastal Health; 2010.

Vancouver Coastal Health. Assessing risk for tooth decay in children 0-5 years. BC (Canada): Vancouver Coastal Health; 2010.

Selected Supplemental Research for Knowledge/Education

Vancouver Coastal Health. Vancouver Community Dental Health Program [Internet]. Vancouver (Canada): Vancouver Coastal Health; c2010 [updated 2010; cited 2010 Nov1]. Available from:http://dentalhealth.vch.ca/

Vancouver Coastal Health. Feeding your toddler: 9-18 months [pamphlet]. Richmond (Canada): Vancouver Coastal Health; 2007. http://www.froghollow.bc.ca/cpp/document/health-feedingtoddler.pdf (milk amount)

Health Canada. Eating well with Canada Food Guide[pamphlet]. Vancouver (Canada): Health Canada, Government of Canada; 2007. http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/food-guide-aliment/

47

view_eatwell_vue_bienmang-eng.pdf

Ministry of Social Development. Healthy Kids Program [Internet]. c2010 [updated 2010 Mar 4; cited 2010 Nov 29]. Available from: http://www.eia.gov.bc.ca/publicat/bcea/Healthykids.htm

Lewis C, Lynch H, Richardson L. Fluoride Varnish use in primary care: what do providers think? Pediatrics. 2005;115:e69-e70.

Kulkarni G, Gartsbein E. The need for an oral Weinstein P, Harrison R, Benton T. Motivating mothers to prevent caries: confirming the beneficial effect of counseling. JADA [internet]. 2006 June, [cited 2010 Oct 31]; 137(6):789. Available from: CINAHL with Full Text.

Da Silva K. A role for the family in children’s oral health. NYSDJ [Internet]. 2007 Aug [cited 2010 Nov 30]; 73(5):55-7. Available from: Family & Society Studies Worldwide.

Amin M, Harrison R. Understanding parents’ oral health behaviours for their young children. Qual Health Res [Internet]. 2009 Jan, [cited 2010 Oct 31]; 19(1):116-27. Available from Academic Search Complete.

Rothe V, Kebriaei A, Pitner S, Balluff M, Salama F. Effectiveness of a presentation on infant oral health care for parents. Int J Paediatr Dent [Internet]. 2010, [cited 2010 Oct 31]; 20(1):37-42. Available from: CINAHL with Full Text.

Harrison R. Oral Health Promotion for high-risk children: case studies from British Columbia. JCDA [Internet]. 2003 May, [cited 2010 Nov11]; 69(5):292-6. Available from: Family & Society Studies Worldwide.

Farhat-McHayleh N, Harfouche A, Souaid P. Techniques for managing behaviour in pediatric dentistry: comparative study of live modeling and tell-show-do-based on children’s heart rates during treatment. JCDA [Internet]. 2009 May, [cited 2010 Oct 31]; 75(4):283. Available from: MEDLINE with Full Text.

Human Early Learning Partnership. EDI community summary Richmond school district 38 [Internet].c2010 [updated 2010 Sept; cited 2010 Nov11]. Available from: http://www.earlylearning.ubc.ca/wp-uploads/web.help.ubc.ca/2010/09/SD-38-CommunitySummary-2010.pdf

Part of population approach, in research and statistics of health of childrencare policy in daycares: reasoning and direction. Oral health Journal. 2008;30-4.

48

APPENDIX H – TEAM REFLECTIONS ON FACILITY

Community/Facility Location: Richmond (Vancouver Coastal Health)Target Audience and Date: Richmond residents – Children age 6 and underTeam members: Rubyjean, Doris, Natasha, Priscilla

If you were a student/participant/resident in this organization what might you be seeing

and thinking? Explore the world through their eyes and reflect on their perspective?

Participants in this program view Vancouver Coastal Health as an organization devoted to

providing community support in a variety of health services, for treatment and prevention. In

their perspective, Vancouver Coastal Health will give them access to health care and other

resources. The organization keeps all personal information confidential and those who run

the program/organization are health care professionals. Therefore, participants feel safe and

secure. Participants experiencing financial difficulties may find this organization helpful

when looking for information about the resources available them, such as the location of

low-cost clinics and eligibility for Healthy Kids Program.

Explore the world through the eyes of someone working in this organization. What might

you be seeing and thinking?

Anyone who works in this organization would feel that he or she has a social responsibility

to promote changes in people’s habits in order to promote health and prevent disease. S/he

must provide treatment/prevention and education in order to achieve program goals. A

health care professional who works in this organization would find that there are a lot of

individuals and families that do not have access to care (especially dental care) in the

community due to financial difficulties. A health care professional faces challenges such as

lack of funding for programs that s/he believes the community would benefit from, as well

as language barriers that would hinder delivery of essential information to those who need it

the most, such as immigrants who are not familiar with the health care system.

49

Based on your observations what are key elements of the philosophy of care in this

organization?

Vancouver Coastal Health is determined to address the unmet needs of the community, such

as access to care, treatment and prevention of disease, and promotion of health. The

organization ensures that quality care is provided and patient confidentiality is respected at

all times. The organization practices interprofessional collaboration in order to address the

varying needs of the community. Advocacy and leadership are given importance in this

organization in order to raise awareness and influence change in public policy with regards

to the health of the community.

What are your observations about important protocols in the organization?

All individuals who participate would have to review the rules and regulations of this

organization (Vancouver Coastal Health) to ensure both client’s and clinician’s safety. All

individuals are to be treated in a professional manner and ensure that all personal

information is kept confidential. Any information or instruction given to a client should be

based on up-to-date evidence and congruent with the program’s objectives.

What evidence do you see of the culture of the organization and the people within it?

Vancouver Coastal Health respects all individuals from different cultural backgrounds and

beliefs. They are determined to solve health disparity and health literacy issues. The

organization respects client confidentiality and therefore provide a safe, secure and

supportive environment to all individuals who seek their services.

50

TEAM REFLECTIONS OF ASSESSEMNT/IMPLEMENTATION

1 ST IMPLEMENTATION (Nov. 3)

Did the observation or lesson implementation go according to plan? Why or Why not?

Yes the implementation went mostly as planed, because we a had a good idea of what we would encounter due to the many role playing scenarios we had rehearsed prior to implementation. However we had 2 cancellations that left us with only three clients for the day. Ms. Enns played a larger role in the implementation than expected, but it was a welcome learning experience.

What was the biggest surprise? What was the biggest challenge?

The biggest surprise and challenge was the difficulty in conducting the actual oral

screenings. We had anticipated it being difficult, but not to the extent experienced, as we

severely underestimated the strength of distressed two year olds. It was extremely difficult

to apply the fluoride varnish while the toddler was moving around, screaming and crying.

What would you do differently next time?

We would try to be more confident and assertive while delivering advice to parents and

quicker during screening and fluoride application as suggested by Ms. Enns.

What have you learned about teamwork and community work through this experience?

It became evident that good communication and teamwork is essential for the appointment

goes smoothly and efficiently. Members split work among the team and supported one

another to during assessments and procedures as needed. Communication with the

receptionist, and collaboration with experts and translators, proved that teamwork was

essential to facilitation of the program, especially given the time restraints. I realized from

this experience how much one person is able do for a community with limited time and

resources. It opened my eyes to how underfunded community dental health is in Richmond,

and the good that can be accomplished in such a short period of time.

51

2 ND IMPLEMENTATION (Nov. 10)

Did the observation or lesson implementation go according to plan? Why or why not?

Implementation went according to plan. Team member gave a brief overview on how to

conduct caries risk assessment and how to apply fluoride varnish effectively. Team

member’s advice was based on experience from previous implementation.


The biggest challenge was the ability to work to time-constraints. We needed more time to

provide counseling to some families but due to time constraints, some important information

was not relayed to them. Another challenge was conveying information to families with

limited English.

What was the most important thing you learned from the session?

We learned how to work efficiently due to time pressure. Also, we learned how to manage

child’s behavior especially during oral screening and application of fluoride varnish.


We would suggest that one team member should do the whole session (caries risk

assessment, oral screening and fluoride varnish application) with one family and delegate

the charting task to the other group member. In this way, both students get the opportunity to

provide all these services to different families. Also, students learn how to manage their time

wisely.

52

3 RD IMPLEMENTATION (Nov. 17)


Mostly it did. The concerns that came up were generally similar- nutrition (milk or food

alternatives), frequency of sugar consumption, and OHI (brushing technique and fluoride

toothpaste), as was practiced at the mock assessment with Ms Enns. However, in terms of

order, we had to acclimate to changes to such.


Almost every child that goes on the knee-to-knee position cried. The surprise would be the

occasional few that did not. For those that didnt’ cry, it may be due to an older age, a still

and calm persona of the child, or the parenting style. The biggest challenge was holding

down a fiercely struggling child during screening, and trying to screen clearly for caries.

Also, for the parents who we were not able to follow up on, it is hard to assess whether they

have been lead from the precontemplation to contemplation stage of change in terms of

controlling the toddler’s lifestyle.


Watching a professional hygienist conduct the interview- the flow, ease, and effectiveness of

the conversation. When appropriate, Ms Enns utilized a more authoritative tone when asking

the child to do something, as they tend to listen to another adult rather than the parent. This

seemed effective in changes in children who make it difficult for the parent to implement

change, such as not letting their parents brush their teeth for them. In addition, it is

important to learn to “let go.” There are many topics we wanted to raise awareness in a

parent within the limited time-frame. We have to only focus on the most concerning issues

first, and not overwhelm the caregiver. Too many changes at once may be deemed

unacceptable to the child as well.

53


Initially, we thought the children that come in would have enough caries lesions for us to

show parents, to raise awareness in what they look like when performing a check. However,

for those children who have not yet had any incipient caries, we should prepare visuals,

whether in printouts or computer, for the parents.


Communication skills with clients and teammates is emphasized. This was especially true

when only two students were able to implement each time, and had to relay all information

to others who were not present. Communication skills must be used with critical thinking to

interpret the experience, rather than simply naming what was seen, which was not very

helpful. For followups, instead of following up on recalls only and doing follow-up calls

halfway into the implementations, this should be done early on since the first

implementation. Moreover, asking open ended questions as opposed to structured yes/no

questions give more room for rapport building.

54

4 TH IMPLEMENTATION (Nov. 24)


Yes the observation and lesson implementation did go according to plan. Because this was

our last implementation, we were more knowledgeable about what our target population was

like. We knew what to expect and was more prepared.


There was no surprise at this implementation. However, there are still some challenges.

The biggest challenge is trying to calm down the toddlers and have them more compliant

during brushing and application of fluoride varnish.


From this session, we learned that teamwork and collaboration is very important. During

implementation, we all worked together with good rhythm ensuring the parents’ and

toddlers’ time there was smooth.


We would think of different methods to calm the child down during the knee to knee dental

exam.


We have learned that teamwork in the community is very significant. Cooperation within

the team helps create a successful implementation.

55

APPENDIX I – DATA FOR POST ASSESSMENT OF PROGRAM EFFICACY

Data collected from follow-up call to families in the 3rd and 4th implementation (7/11parents)

Statement Quantitative Measure Effectiveness

Still has the checklist. 5 – YES2 – NO

71%

Follows at least some of the recommended changes on checklist.

7 – YES0 – NO

100%

Follows all the recommended changes on checklist.

2 – YES5 – NO

29%

Have further questions about checklist. *

0 –YES7 – NO

0%

Found the checklist useful. 5 – YES2 – NO

71%

Skills/information from the program was useful and worthwhile.

7 – YES0 – NO

100%

Program was a positive experience.

7 – YES0 – NO

100%

56

APPENDIX J – REFERENCES

1. Lalond M. A new perspective on the health of Canadians: A working document. Ottawa (Canada): Government of Canada; 1974.

2. Statistics Canada. [cited 2010 Nov 18]. Available from http://www12.statcan.ca/census-recensement/2006/dp-pd/prof/92-591/search-recherche/frm_res.cfm?Lang=E.

3. Enns L. Dental Public Health for Children. BC [unpublished lecture notes]. Vancouver Coastal Health; lecture given 2010 Oct 20

4. City of Richmond. [cited 2010 Nov 18]. Available from: http://www.richmond.ca.

5. Vancouver Coastal Health. [cited 2010 Nov 18]. Available from: http://www.vch.ca.

6. Vancouver Coastal Health. Vancouver Community Dental Health Program. [cited 2010 Nov 18]. Available from http://dentalhealth.vch.ca/.

7. Weintraub JA, Ramos-Gomez, Jue B, Shain S, Hoover CI, Featherstone JDB, et al. Fluoride varnish efficacy in preventing early childhood caries. J Dent Res [Internet]. 2006 [cited 2010 Nov 18]; 85(2): 172-6.

8. Ottawa Charter for Health Promotion. First International Conference on Health Promotion; 1986 Nov 21; Ottawa (Canada): WHO; 1986. http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf

9. Weinstein P, Harrison R, Benton T. Motivating parents to prevent caries in their young children: one-year findings. JADA [Internet]. (2004 June), [cited 2010 Oct 15]; 135 (6): 731-738. Available from: CINAHL with Full Text

10. Miller E, Lee J, DeWalt D, Vann W. Impact of Caregiver Literacy on Children’s Oral Health Outcomes. Pediatrics [Internet]. (2010 July), [cited 2010 October 15]; 126(1): 107-114. Available from: Academic Search Complete.

11. BC Medical Association. Health literacy- taking an active role in your health [Internet]. c2007 [updated 2007;cited 2010 Nov 29]. Available from: https://www.bcma.org/health-literacy-taking-active-role-your-health

12. Citizenship and Immigration Canada. [cited 2010 Nov 23]. Available from http://www.fasadmin.com/images/pdf/%7B1638A6AC-5AF1-4EF3-94AE-4A9A6756EF75%7D_IFH%20Manual.pdf

13. Ministry of Social Development. [cited 2010 Nov 18]. Available from http://www.eia.gov.bc.ca/publicat/bcea/Healthykids.htm.

57

14. Harrison R. Oral Health Promotion for high-risk children: case studies from British Columbia. JCDA [Internet]. 2003 May, [cited 2010 Nov11]; 69(5):292-6. Available from: Family & Society Studies Worldwide.

15. Human Early Learning Partnership. Analysis & Mapping of the 2006/07 British Columbia Kindergarten dental survey. BC (Canada): University of British Columbia; 2009.

16. Gehshan S, program director. Access to oral health services for low-income people-policy barriers and opportunities for intervention for The Robert Wood Johnson Foundation: 2002: Proceedings of the National Conference of State Legislatures; 2002 Jan; Princeton, New Jersey, USA.

58

APPENDIX K - ARTICLES FOR SITUATIONAL ANALYSIS

59

Documents

blogs.ubc.cablogs.ubc.ca/pkaljanac/files/2011/11/Community-Repor… · Web viewThis coverage includes services such as exams, x-rays, fillings, cleanings and extractions.14 Emergency