evaluation of bc early childhood dental programs · evaluation of bc early childhood dental...

EvaluationofBCEarlyChildhoodDentalPrograms

EARLY CHILDHOOD SCREENINGRESEARCH & EVALUATION UNIT

FINAL REPORT

ThisdocumentwaspreparedfortheEarlyChildhoodDentalEvaluationSubcommitteebytheHumanEarlyLearningPartnership’sEarlyChildhoodScreeningResearchandEvaluationUnitattheUniversityofBritishColumbia.

July,2011

EARLY CHILDHOOD SCREENINGRESEARCH & EVALUATION UNIT

PrinciPal investigator

Brenda Poon

co-PrinciPal investigator

Clyde Hertzman

research and evaluation Manager

Paul Holley

research and evaluation coordinator

amBer louie

research assistants

deBoraH Heard, deClan Hsu, allyson rayner Celina Vergel de dios

data analyst

anna KrasnoVa

sPatial data analyst and cartograPher

antHony smitH

Evaluation of BC Early Childhood Dental Programs - Final Report

Contents

i ABOUTTHEEVALUATIONTEAM

ii ABOUTTHEHUMANEARLYLEARNINGPARTNERSHIP

iii BACKGROUNDANDOVERVIEW

1 EARLYCHILDHOODCARIESANDBCEARLYCHILDHOODDENTALPROGRAMS

5 BCEARLYCHILDHOODDENTALPROGRAMSLOGICMODEL

7 EVALUATIONMEASURESANDMETHODS7 DefiningandMeasuringEarlyChildhoodCaries8 TheKindergartenDentalSurveyinBritishColumbia:ABriefOverview9 EnvironmentalScan10 FocusGroupswithPublicHealthDentalStaff11 ProvincialandRegionalMapping

12EVALUATIONFINDINGS

13EARLYCHILDHOODDENTALHEALTHSURVEILLANCE13 1.Istheoralhealthofyoungchildrenimproving?Bycommunity?By

vulnerability?14 EarlyChildhoodCariesinBritishColumbia’sHealthAuthoritiesand

HealthRegions17 EarlyChildhoodCariesbySchoolDistrictandHELP

Neighbourhoods22 SocioeconomicInfluencesofEarlyChildhoodOralHealthinBritish

Columbia29 On-andOff-Diagonals31 VisibleDentalDecayRatesandEarlyChildDevelopmentIndicators

33 Summary

34RISKASSESSMENT34 2.Arethecurrentdentalhealthriskassessment/screenguidelinesimplementedas

intended?34 2i.Whatstandardizeddentalhealthriskassessmenttool/questionsshouldbe

usedwithchildrenaged0-5(includingkindergartenentry)inBC?35 2ii.Atwhatage(s)shouldthesebeadministered?35 2iii.Whoshouldadministerthedentalhealthriskassessment?36 2iv.Whatguidelinesandfollow-upproceduresshouldbeused?37 2v.Towhatextentdoesthedentalhealthriskassessment/screeningreachyoung

children?38 2vi.Towhatextentdoestheprogramidentifyabroadspectrumofchildrenat

riskforcaries?38 2vii.Forthoseeligiblechildrenwhodentalpublichealthisnotreaching,whatare

thebarriers?41 Summary


Contentscontinued...

42HEALTHPROMOTIONANDPREVENTIVESTRATEGIES42 3.Arehealthpromotioninterventionseffectiveinsupportingfamilydentalhealth

practicestowardreducingearlychildhoodcaries?

43BUILDINGPARTNERSHIPS43 4.Whatstrategiesareusedinthehealthauthoritiestopreventearly

childhooddentaldisease?Whatisthemosteffectivecombinationofstrategiesbeingprovidedinthehealthauthoritiestopreventearlychildhooddentaldisease?

46 Whatarethemosteffectivecombinationsofstrategiesbeingusedtoreduceearlychildhoodcaries?

47 Summary

48GENERALTHEMES

52STRENGTHSANDLIMITATIONSOFTHEEVALUATIONPROCESS52 Strengths54 Limitations

55RECOMMENDATIONS

58REFERENCES

63APPENDIXA:EvaluationMatrix

65APPENDIXB:ListofEvaluationReports,Documents&Maps

67APPENDIXC:SummaryofSelectedStudiesUtilizingtheBasicScreeningSurvey

68APPENDIXD:MethodologicalNotes

72APPENDIXE:HELPSESScalesandSubscales

74 APPENDIXF:KeyMessagesInOralHealth-relatedPublicHealthHandouts

Listoffigures3 Figure1.BCEarlyChildhoodDentalHealthPrograms6 Figure2.2007BCEarlyChildhoodDentalProgramLogicModel10 Figure3.BCKindergartenDentalSurveyCoveragebyHealthAuthority16 Figure4.KindergartenDentalHealthOutcomesbyHealthAuthority19 Figure5.1.MapofBritishColumbiaDepictingthePercentageofKindergarten

StudentsIdentifiedasHavingVisibleDentalDecayin2009/10bySchoolDistrict21 Figure5.2.TsawwassenNorth(VCHA)21 Figure5.3SunValley(FHA)21 Figure5.4 Rockland(VIHA)21 Figure5.5DawsonCreek(NHA)23 Figure6.SESandDemographicMeasuresforProvinceandHealthAuthorities25 Figure7.VisibleDentalDecayRatesbyHELPSESPercentile


Contentscontinued...

Listoftables9 Table1.BCKindergartenDentalSurveyCoverageforHealthRegionsbySurvey

Year15 Table2.1.KindergartenDentalHealthOutcomesbySurveyYearforHealth

Regions16 Table2.2.KindergartenDentalHealthOutcomesandNumberofKindergarten

StudentsSurveyedin2006/0717 Table2.3.KindergartenDentalHealthOutcomesandNumberofKindergarten

StudentsSurveyedin2009/10byHealthRegion18 Table2.4.ChangeinKindergartenDentalHealthOutcomesandNumberof

KindergartenStudentsAffectedbyHealthRegion20 Table3.1.NeighbourhoodsWitha25%orGreaterChangein%VisibleDental

DecayBetweenSurveyYears20 Table3.2.SchoolDistrictswithConsistentVisibleDentalDecayRatesAcross

SurveyYears22 Table4.SocioeconomicStatus(SES)andDemographicInformationforProvince

andHAs24 Table5.VisibleDentalDecay(Code02+03)RatesbyNeighbourhood

SocioeconomicStatus(basedonoverallHELPSESIndex)24 Table6.1.CorrelationsbetweenSubcommitteeSES/DemographicMeasuresand

%VisibleDentalDecay(Code02+03)25 Table6.2.CorrelationsbetweenHELPSESIndexandSubcomponentsand%

VisibleDentalDecay(Code02+03)26 Table7.1.RegressionAnalysisforSES(Subcommittee)and%VisibleDental

Decay(Code02+03)27 Table7.2.RegressionAnalysisforSES(HELP)and%VisibleDentalDecay(Code

02+03)28 Table8.1.SubcommitteeSES/DemographicImportanceScoresinPredictingthe

%VisibleDentalDecay(Code02+03)29 Table8.2.HELPSESIndexandComponentImportanceScoresinPredicitingthe

%VisibleDentalDecay(Code02+03)30 Table9.SummaryofNeighbourhoodOn/Off-Diagonals(SESDental)30 Table10.NeighbourhoodOff-Diagonals(SESDental)31 Table11.EDI(Wave3)VulnerabilityRates(%)forProvinceandHAs32 Table12.CorrelationsbetweenEDIVulnerabilityRates(Wave3)and%Visible

DentalDecay(Code02+03)32 Table13.RegressionAnalysisfor%VisibleDentalDecay(Code02+03)and

EDIVulnerabilityRates(Wave3)


i

ABOUT THE EVALUATION TEAM

BrendaPoon,PrincipalInvestigator,isanAssistantProfessorattheHumanEarlyLearningPartnership(HELP),CollegeforInterdisciplinaryStudiesatUBC,andanAssociatefacultymemberintheSchoolofPopulationandPublicHealthatUBC.

ClydeHertzman,Co-PrincipalInvestigator,isDirectorofHELP,CollegeforInterdisciplinaryStudiesatUBC;CanadaResearchChairinPopulationHealthandHumanDevelopment;andProfessorintheSchoolofPopulationandPublicHealthatUBC.

PaulHolley,ResearchandEvaluationManager,holdsadoctorateinSociologyandspecializesinprogramevaluation,grantwriting,andstatisticalanalysis.Paul’scurrentresearchinterestsrelatetoearlychildhooddevelopmentandadolescentdrugandviolenceprevention.

AmberLouie,ResearchandEvaluationCoordinator,holdsanMScinPopulationHealth.Shebringsexperienceinqualitativemethods,questionnairedesign,statisticalanalysis,systematicliteraturereviews,andhealthservicesevaluation.

TheevaluationteamalsoincludesfourResearchAssistants,onedataanalystandadataanalyst/cartographer.ThefourresearchassistantsareDeclanHsu(BA),CelinaVergeldeDios(MA),DeborahHeard(BA&Sc),andAllysonRayner(MA),eachofwhomhaveabackgroundinearlychilddevelopmentanddevelopmentalpsychology.ThedataanalystisAnnaKrasnova(BSc)whohasabackgroundindataprocessingmethodologies.AnthonySmith(BA)isthedataanalystandcartographer,hisresearchinterestsincludesustainableurbandesign,spatialstatisticsandgeographicdatavisualization.


ii

ABOUT THE HUMAN EARLY LEARNING PARTNERSHIP

TheHumanEarlyLearningPartnership(HELP)isaconsortiumoffivemajoruniversitiesinBritishColumbiathatfostersinnovationthroughnetworkingandcollaborationamongstresearchersattheUniversityofBritishColumbia,theUniversityofVictoria,SimonFraserUniversity,UniversityofNorthernBritishColumbia,andThompsonRiversUniversity.ItisthefocalpointforearlychilddevelopmentresearchinBritishColumbia.HELPconductsresearchthataimstohelpchildrenandfamiliesthrive.Toachieveitsgoals,HELPworkscloselywithcommunitiesacrossBCtodrawontheirexpertiseaboutlocalfactorsthatdeterminechildren’soutcomes.

HELP’sresearchapproachintegratesbehaviouralandsocialscienceswiththebiomedicalsciences.ResearchconductedatHELPshowshowtheenvironmentsthatchildrenspendtheirtimeinduringtheirearlyyears“sculpt”theirbrains.Thissculptingprocessaffectslife-longhealth,well-being,learningandbehaviour.Withitsinterdisciplinaryapproach,HELPaimstomakeauniqueinternationalresearchcontributiontounderstandingthebiological,psychologicalandsocietalfactorsthatinfluencechildren’shealthanddevelopment.Inpursuitofthismission,HELPwill:

• Highlighttheimportanceoftheearlyyearsonhealth&development.• Utilizealongitudinal,life-courseperspective.• Facilitatecell-to-societyresearchcollaborationsanddiscourse.• Fosterinter-disciplinary,inter-institutional,inter-culturalandinter-sectoralpartnerships.

• Facilitateknowledgeexchangecapableoftransforminglivesandcommunities.

HELPistheworld’sfirstconsortiumofresearchersinterestedinbringingapopulation-basedperspectivetoearlychilddevelopment.Overthelastdecade,throughanalysisofdevelopmentaltrajectoriesofentirepopulationsofchildren,HELPhasproducedresearchthatdocumentssystematicdifferencesinchildren’slongtermhealthanddevelopmentandthesocialdeterminantsthataccountforthesedifferences.


iii

BACKGROUND AND OVERVIEW

In2005,BritishColumbia’sMinistryofHealth(MoH)establishedaprovince-widegoalinrelationtoearlychildhooddentalhealth:60%ofBritishColumbia’skindergartenpopulationwillhave“novisibledecayexperience.”Inotherwords,threeoutoffivekindergartenchildreninBCwhosedentalhealthwascheckedthroughastandardizedpublichealthvisualdentalsurveytoolwillbe“caries-free.”

Todetermineprogresstowardthisprovincialgoal,theMoHapproachedtheHumanEarlyLearningPartnership(HELP)attheUniversityofBritishColumbia(UBC)in2006toconductasystematicfour-yearevaluationoftheBCEarlyChildhoodDentalPrograms.ThestatedpurposeoftheevaluationistoassesstheeffectivenessofexistingBCEarlyChildhoodDentalProgramstoimprovethedentalhealthofchildreninBC.Asaleaderinpopulation-basedearlychilddevelopmentresearchinBritishColumbia,HELPwaswellpositionedtoinvestigateBC’searlychildhooddentalprogramsinrelationtothedevelopmentofchildrenovertime,alongwithfactorsthatcanpromoteorunderminehealthychilddevelopment.HELPalsoenhancedtheprojectwiththeabilitytodrawlinkagesbetweendentaloutcomesandneighbourhoodleveldatainregardstoschoolreadinessasmeasuredbytheEarlyDevelopmentInstrument(EDI).

InApril2007,aDentalEvaluationSubcommitteewasformedtoproviderecommendationsforthedevelopmentandimplementationoftheevaluationplanforBC’searlychildhooddentalprograms.TheSubcommitteeiscomprisedofrepresentativesfromeachoftheprovince’sfiveregionalhealthauthorities,theMinistryofHealth,BCInitiativesandtheNationalCollaboratingCentreforAboriginalHealth,andtheHELPevaluationteamfromUBC.Otherindividualsandorganizationswerealsoconsultedonanadhocbasistoenhancethediversityofexperienceandexpertiseinthegroup.AkeyfunctionoftheSubcommitteewastoensuretheevaluationplanreflectedprogramobjectivesandkeystakeholderinput,andthatitwouldinformprogramplanningandmonitoring.ThecommitteefocusedoncomponentsoftheplanthathadsharedrelevanceandsignificanceacrossHealthAuthoritiesandacrossvariousstakeholders.

TheSubcommitteemetregularlytodevelopanevaluationframeworktoguidethefour-yearproject1.Fouroverarchingevaluationquestionswereestablished:

1. Istheoralhealthofyoungchildrenimproving?Bycommunity?Byvulnerability?

2. Arethecurrentdentalhealthriskassessment/screenguidelinesimplementedasintended(i.e.,appropriatereferralsbypublichealthnurses)?Whatstandardizeddentalhealthriskassessmenttool/questionsshouldbeusedwithchildrenaged0-5(includingkindergartenentry)inBC?Atwhatage(s)shouldthesebeadministered?Whoshouldadministerthedentalhealthriskassessment?Whatguidelinesandfollow-upshouldbeused?Towhatextentdoesthedentalhealthriskassessment/screeningreachyoungchildren?Towhatextentdoestheprogramidentifyabroadspectrumofchildrenatriskforcaries?Forthoseeligiblechildrenwhodentalpublichealthisnotreaching,whatarethebarriers?

1HumanEarlyLearningPartnershipEvaluationTeam,BC Early Childhood Vision Screening Program: Evaluation Framework Overview(Vancouver,BC:UniversityofBritishColumbia,2009).


iv

3. Howeffectivearehealthpromotioninterventions(e.g.,keymessages)insupportingfamilydentalhealthpracticestowardreducingearlychildhood?

4. Whatstrategiesareusedinthehealthauthoritiestopreventearlychildhooddentaldisease?Whatisthemosteffectivecombinationofstrategiesbeingprovidedinthehealthauthoritiestopreventearlychildhooddentaldisease?

Toguidedatacollectionandanalysesandtoensurethattheevaluationprocessremainedfocusedonthefourevaluationquestionsabove,anevaluationmatrixwasdevelopedattheoutsetoftheproject(seeAppendixA).Thematrixdefinedandlinkedthedentalissuespertinenttotheevaluationwiththefollowing:1)evaluationquestions,2)keyoutcomemeasuresanddatasources,and3)atimeline.ThematrixwascompletedincollaborationwiththeMinistryofHealthandregionalhealthauthorities,andwasakeytoolinunderstandingeachpartner’srolesandresponsibilities.

Thereportpresentedhereinrespondstoeachofthefourevaluationquestionsthroughasynthesisofqualitativeandquantitativefindingsthatweregeneratedoverthecourseofthefour-yearevaluationproject(seeAppendixBforalistofevaluationreportsanddocuments).

ThereportbeginswithabriefoverviewofselectedresearchrelatedtoearlychildhoodcariesaswellastheBCEarlyChildhoodDentalPrograms.Asummaryofthedataandmethodologiesusedintheevaluationprocessisfollowedbyapresentationoftheevaluationfindings.Theevaluationfindingshavebeenorganizedinthisreportaccordingtothefouroverarchingevaluationquestionsand,morebroadly,intothefollowingfourmaincategories:surveillance,riskassessment,healthpromotionandpreventionstrategies,andbuildingpartnerships.

Thefocusofthesurveillancesectionisapresentationofselectedfindingsfromtheanalysisofthe2006/07and2009/10KindergartenDentalSurveys.Resultsarepresentedfortheprovince,healthauthorities,andhealthservicedeliveryareasinrelationtosocioeconomicstatus,demographicsfactorsandearlychilddevelopment.Followingthisdiscussionofdentalhealthsurveillance,isareviewoftheresultsdrawnfromtheprovince-widefocusgroups.Thesequalitativefindingsarefirstpresentedinrelationtoriskassessmentsandtheirguidelines,respectivetools,recommendedtools,follow-upproceduresandprogramreach.Resultsarepresentedintermsofcurrentproceduresandrecommendedprocedures.Abriefdiscussionisthenpresentedonhealthpromotionstrategiesanddentalhealth,followedbyanexplorationofpartnershipbuildingasaneffectivestrategyforpreventingdentaldecay.ThereportconcludeswithanoverviewofthekeythemesthathaveemergedfromthedataandfourbroadrecommendationsforconsiderationwithrespecttotheBCEarlyChildhoodDentalPrograms.


EARLY CHILDHOOD CARIES AND BC EARLY CHILDHOOD DENTAL PROGRAMS

Dentalhealthisessentialtothehealthofthepopulationasithasfar-reachingimplicationsforchildrenandadults.Inadulthood,forinstance,poororalhealthcannegativelyimpactpotentialjobopportunities,publicspeaking,andothersocialinteractions.2Amongchildren,EarlyChildhoodCaries(ECC),atermusedtodescribetoothdecayfoundinchildren71monthsandyounger,isthemostcommonchronicdisease–fivetimesmoreprevalentthanasthmaandtwentytimesmoreprevalentthandiabetes.3Earlychildhoodcariesisaninfectiousdiseaseinvolvingacombinationoffactors,includingsocial,behavioral,microbiologic,environmental,andclinicalfactors.4Thediseaseoccursworldwide,afflictingpredominantlydisadvantagedchildren.5Fourcohortstudieshaveshownthatchildrenwithpreviouscariesexperienceareatelevatedriskforfuturecaries.6, 7, 8, 9Children’soralhealthimpactstheirsocialfunctioningandeconomicproductivitylaterinlife.10

Instudiesofchildrenundertheageof6,dentaldecayorearlychildhoodcarieshasbeenlinkedtoembarrassment,increasedirritability,andfewersocialinteractions.11, 12Dentaldecayisalsorelatedtoachild’ssubsequenthealthandemotionaldevelopment.Amongchildrenaged4to15,carieshasbeensignificantlyassociatedwithadverseaffectsonsmiling,self-confidenceandemotionalwell-being.13, 14,15, 16Researchhasalsofoundthatdentaldecayaffectsthequalityoflifeforchildren,includingchildrenfromaffluentfamilies,17withloweroverallhappinessforchildrenexperiencingdentaldecay.

Whiletherearemanypotentialcausesofearlychildhoodcaries,oneofthemostimportantfactorsissocioeconomicstatus(SES),whichisusedtodescribethesocialandeconomicwellbeingofachild’sfamily,neighbourhoodandschool.

2A.N.Astrometal.,“OralimpactsondailyperformanceinNorwegianadults:theinfluenceofage,numberofmissingteeth,andsocio-demographicfactors,”European Journal of Oral Sciences114,no.2(2006):115-121.3CanadianAssociationofPediatricHealthCentres,“EarlyChildhoodCaries:AnEpidemicandPandemicinNorthAmerica”,2007,http://www.caphc.org/documents_annual/2007/conference_ppts/16_10_2007/cc1/k_morley.pdf.4AmericanAcademyofPediatricDentistryCouncilonClinicalAffairs,“Policyonuseofacaries-riskassessmenttool(CAT)forinfants,children,andadolescents,”Pediatr Dent29,no.7(2006):25-7.5R.J.Berkowitz,“Causes,treatmentandpreventionofearlychildhoodcaries:Amicrobiologicperspective,”Journal of the Canadian Dental Association69,no.5(2003):304-307.6M.Grindefjordetal.,“Predictionofdentalcariesdevelopmentin1-year-oldchildren,”Caries Research29,no.5(1995):343-348.7S.R.Saemundssonetal.,“Thebasisforclinicians’cariesriskgroupinginchildren,”Pediatric Dentistry19,no.5(1997):331-338.8A.Wandera,S.Bhakta,andT.Barker,“Cariespredictionandindicatorsusingapediatricriskassessmentteachingtool,”ASDC Journal of DentistryforChildren67,no.6(2000):408-412,375.9L.K.Wendt,A.L.Hallonsten,andG.Koch,“Oralhealthinpre-schoolchildrenlivinginSweden.PartIII--Alongitudinalstudy.Riskanalysesbasedoncariesprevalenceat3yearsofageandimmigrantstatus,”Swedish Dental Journal23,no.1(1999):17-25.10JoelH.BergandRebeccaL.Slayton,eds.,Early childhood oral health(Ames,Iowa:Wiley-Blackwell,2009).11S.Feitosa,V.Colares,andJ.Pinkham,“Thepsychosocialeffectsofseverecariesin4-year-oldchildreninRecife,Pernambuco,Brazil,”Cad.Saude Publica21,no.5(2005):1550-1556.12S.LFilstrupetal.,“Earlychildhoodcariesandqualityoflife:Childandparentperspectives,”Pediatric dentistry25,no.5(2003):431–440.13N.M.Nuttalletal.,“ThereportedimpactoforalconditiononchildrenintheUnitedKingdom,2003,”Br DentJ200,no.10(2006):551-556.14R.R.Patel,R.Tootla,andM.R.Inglehart,“Doesoralhealthaffectselfperceptions,parentalratingsandvideo-basedassessmentsofchildren’ssmiles?,”Community Dentistry and Oral Epidemiology35,no.1(2007):44-52.15H.Yusufetal.,“ValidationofanEnglishversionoftheChild-OIDPindex,anoralhealth-relatedqualityoflifemeasureforchildren,”Health and Quality of Life Outcomes4(2006):38.16L.A.FosterPageetal.,“ValidationoftheChildPerceptionsQuestionnaire(CPQ11-14),”Journal of Dental Research84,no.7(2005):649-652.17D.Locker,“Disparitiesinoralhealth-relatedqualityoflifeinapopulationofCanadianchildren,”Community Dentistry and Oral Epidemiology35,no.5(2007):348-356.


TherelationshipbetweenSESandECCappearstobeconsistentacrossmultiplemeasuresofSES,includingTownsend’andJarman’sSESscores,18,19whichrelatetoneighbourhood-levelcharacteristicssuchasunemployment,homeownership,householdswithchildrenunder5years,singleparentfamilies,andfirstgenerationcitizens.TherelationshipbetweenSESanddentalhealthalsoholdsstrongacrossindividual-levelmeasuressuchaseducationalattainment,20ethnicityandhouseholdincome(basedontheUSNationalHealthandNutritionExaminationSurvey).21

InBC,alargenumberofchildrenexperiencedentaldecaybeforekindergartenandrequireimmediatetreatment.Duetochallengesinprovidingdentaltreatmentforyoungchildren(e.g.,levelsofchildfearandcooperationduringdentalvisits),suchtreatmentofteninvolvestheuseofgeneralanestheticservicesinhospitalsettings.In2002,resultsfromthepublichealthvisualdentalsurveyindicatedthat41percentofchildrensurveyedinBChadexperiencedsomeformofdentalcariesbythetimetheyreachedkindergarten.22ThisisconsistentwithfindingsrelatedtoearlychilddevelopmentoutcomesinBCindicatingthatahighproportion(one-quarter)ofyoungchildrenintheprovincewasdevelopmentallyat-riskorvulnerablein2001-2004.23

Whilechildhoodtoothdecayiscommon,itisalsopreventable;thediseaseismultifactorialinnaturebuttheextentornumberofteethaffectedcanbeinfluencedbypreventivemeasures.Earlyinterventionprogramsareanimportantelementofdentalpublichealthservicedeliveryastheyseektoincreasethepotentialforchildrentoremaindiseasefree.Duetoitsimpactonhealthandtheinequitiesinaccesstoregularpreventiveandrestorativedentalcare,thepreventionofdentaldiseasesisacorefunctionofpublichealthInBC,anddentalhealthisrecognizedasoneofthecoreprogramsforpublichealthservicesacrosstheprovince.24TheModelCoreProgramPaperforDentalPublicHealth(2006)25providesdirectionforpublichealthpreventionservicesinBC,identifyingthreecorefunctionsforthedeliveryofdentalpublichealthprograms:

1. Dentalhealthpromotion.2. Preventionofdentaldisease,withafocusonpreventionofchildhooddentaldiseases.

3. Surveillance,assessmentandevaluationofchildhooddentalhealthstatusanddentalhealthprograms.

Inordertoimprovethedentalhealthstatusofyoungchildren,theBCEarlyChildhoodDentalProgramsaimto:(a)provideuniversalaccesstoearlyassessmentforchildrenunderagesixand(b)identifychildrenneedingdentaltreatment(seeFigure1).

18C.M.JonesandH.Worthington,“Fluoridation:Therelationshipbetweenwaterfluoridationandsocioeconomicdeprivationontoothdecayin5-year-oldchildren,”Br Dent J186,no.8(1999):397-400.19C.M.Jonesetal.,“Waterfluoridation,toothdecayin5yearolds,andsocialdeprivationmeasuredbytheJarmanscore:analysisofdatafromBritishdentalsurveys,”BMJ315,no.7107(1997):514-517.20A.IsmailandW.Sohn,“Theimpactofuniversalaccesstodentalcareondisparitiesincariesexperienceinchildren,”Journal of the American Dental Association132,no.3(2001):295-303.21C.M.Vargas,J.J.Crall,andD.A.Schneider,“Sociodemographicdistributionofpediatricdentalcaries:NHANESIII,1988-1994,”J.Am.Dent.Assoc.129,no.9(1998):1229-1238.22BritishColumbiaMinistryofHealth,British Columbia’s School Screening Dental Program, A Regional and Provincial Analysis(Victoria,BC:BritishColumbiaMinistryofHealth,2003).23P.W.Kershawetal.,“TheBritishColumbiaAtlasofChildDevelopment,”Canadian Western Geographical Series40(2005):1203-1178. 24BCMinistryofHealth,The Evidence Base for Preventive Strategies in Dental Public Health,EvidenceReview(Victoria,BC:BCMinistryofHealth,2006).25P.Pallan,L.Siebold,andM.Hollander,Model Core Program Paper for Dental Public Health(Victoria,BC:BritishColumbiaMinistryofHealth,2006).


Figure 1. BC Early Childhood Dental Health Programs26

26InformationintheabovefigureisrepresentativeofBCearlychildhooddentalprogramsasof2008(adaptedfromFigure1inthereportDental Health of BC Children in Relation to Social Determinants and Early Child Development: Analysis and Mapping of the 2006/07 British Columbia Kindergarten Dental Survey).

Dental Health Risk Assessment

Assessmentsarecompletedtodetermineriskforearlychildhooddentaldecay.Questionstypicallyrelatetodentistvisits,sibling/parentdentaldecay,toothbrushing,useoffluoridetoothpaste,feedingpractices,andbarrierstoaccess.

Assessmentmayinclude:• 1-to-1educationtoparentsemphasizingkeymessagesrelatedto:dentistvisits,signsofdecay,toothbrushing,useoffluoridetoothpaste,feedingpractices,andlow-costtreatmentoptions.

• Dentalandnutritionhandoutsandtoothbrushes(asavailable).

• Referralforadditionalassessmentanddentistasappropriate.

• ReferraltoFluorideVarnishProgram(seebelow)forchildrenathighriskofdentaldecay.

Selected Examples of Dental Health Risk Assessment Tools

•ToothTalkQuestionnaire(IHA)•12-MonthQuestionnaire(conductedbymailwithatelephonefollow-upquestionnaire)andChildHealthClinics(CHCs)at12-monthimmunizations(NHA).

•PublicHealthNurse(PHN)RiskAssessmentfordevelopingcavitiesatChildHealthClinics(CHC),andPHNIntegratedriskscreeningatCHCs(VIHA).

Fluoride Varnish Program

Dentalstaffprovidefluoridevarnishtochildrenagedfiveandunderthathavebeenassessedathighriskfordentaldecay.Thevarnishtakesjustafewminutestoputontheteeth,andcanhelppreventtoothdecayfromstartingandslowtheprogressionofexistingdecay.Applicationsaretypicallydoneinonetofourshortappointments,buttheremaybeuptosixapplicationsdependingonthechild’sneeds.Fluoridevarnishapplicationsareprovidedalongwithariskassessmentandone-to-oneeducationwiththeparent(s)and/orguardian(s).

Kindergarten Dental Survey

DentalstaffuseasmalllightandtonguedepressortoperformthesurveyonKindergartenstudents,inorderto:• Identifydentalhealthproblemsinchildren;• Collectdatatoidentifyprovincialtrendsindentalhealth;• DeterminetheprevalenceofdentaldecayinBC;and• Identifycasesforreferraland,insomeregions,facilitateaccesstotreatment(whenrequired).

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Figure1aboveprovidesinformationaboutthevariousprogramsandservicesthatcompriseBC’sEarlyChildhoodDentalPrograms.Attheregionallevel,dentalpublichealthprogramscanbedeliveredinvariouswaystomeetuniqueneedswithineachhealthauthority.

The Dental Health Risk Assessment Programsinvolveassessmentofyoungchildrenaswellaschildreninvulnerablepopulations.Theassessment,oftenreferredtoasaCariesRiskAssessment(CRA),providesdentalprogramstaffwithopportunitiestoprovidepreventiveeducationtofamilies.Theriskassessmenttypicallyinvolvesparentsandfamiliescompletinganassessmentrelatedtoearlyidentificationofcaries,appropriateoralhealthpractices,andaccesstoservices.Ifdeemedappropriate,programstaffreferfamiliestothefluoridevarnishprogramortothedentistfordiagnosisandtreatment.

The BC Kindergarten Dental Survey (formerlyknownastheBCSchoolDentalScreeningProgram)wasintroducedin1990.UnderthePublicHealthDentalProgram,registeredDentalHygienistsandCertifiedDentalAssistantsperformavisualcheckfordentaldecayinkindergartenchildrenbetweentheagesof4and6.Itisimportanttonotethatthischeckdoesnotreplacearegulardentalexam.Thepurposeofthesurveyistodeterminetheprevalenceofobviousorvisibledentaldecay,toidentifytrendsindentalhealth,andwherepossible,toobtainameasureoftheeffectivenessofearlychildhoodpreventionactivitiesonthismultifactorialdisease.Thesurveyhasalsobeenusedinsomeregionstoidentifycasesforreferralandfacilitateaccesstotreatmentwhenrequired.


BC EARLY CHILDHOOD DENTAL PROGRAMS LOGIC MODEL

Alogicmodelapproachenhancestheclarityandusefulnessoftheevaluationbyfocusingonissues(andoutcomes)ofvaluetothevariouspartiesinvolvedwithorpotentiallyinfluencedbytheprogrambeingexamined.ThelogicmodelpresentedinFigure2(seebelow)providesasystematicwayofexaminingrelationshipsamongtheresourcesdedicatedtoBC’sDentalPrograms,theactivitiesthatareundertaken,andthechangesorresultsthatareachieved(oranticipated).Themodelillustratesthefollowing:

• Resourcesneededtoaccomplishprogramactivitiesandinfluentialfactors,• Activitiestobeaccomplishedbytheprogram,• Outputsorimmediateresultstheactivitieswillproduce,• Short and long-term outcomesexpected,and• Longer-termimpactsoftheaccomplishedactivities.

Eachofthesefivecomponentsillustratestheconnectionbetweentheeffortsandworkthatgointoprogramoperationsandtheintendedresults.Thislogicmodelprovidedacommonstartingpointfordiscussionoftheprioritiesfortheevaluationprojectandinturnthedevelopmentofthefouroverarchingevaluationquestions.

Thelogicmodelwasusedtodevelopamulti-phaseevaluationplan,includingelementsofclarification,interactive,monitoring,andimpactevaluation.27Clarificationevaluationaimstomakeexplicittheessentialfeaturesoftheprogram,whileinteractiveevaluationassistsprogramplannerstomakedecisionsaboutwaystoimprovetheprogram.Monitoringallowsforevaluationofthecurrentstateofaprogram,whileimpactevaluationassessestheeffectsofprogramactivitiesontargetpopulationsovertime.Throughouttheprocess,autilization-focusedapproachwasalsoemployedtogivecarefulconsiderationforhowintendeduserswouldapplyevaluationfindings.28

Whiletheoriginallogicmodelandevaluationquestionsencompassedcontext,activities,andoutcomes,thedatacollectionultimatelycenteredonprogramactivitiesandimplementation(clarification,interactive,andmonitoringevaluation),ratherthaneffectivenessandoutcomes(impactevaluation).TheprimaryfocusofdatacollectionwastheBCSchoolDentalScreeningProgramintroducedin1990,aswellasthedentalhealthriskassessmentprojectsinitiatedin1996.29Ouranalysiscenteredontwoprimarydatasets:thestatisticsgatheredfromthe2006/07and2009/10BCKindergartenDentalSurveysandthequalitativedatagatheredfromfocusgroupswithpublichealthdentalstaff.

27J.Owen,Program Evaluation: Forms and Approaches(NewYork,NY:GuilfordPress,2006).28MichaelPatton,Utilization-focused evaluation,4thed.(ThousandOaksCalif.:SagePublications,2008). 29Inthisevaluationproject,dentalhealthriskassessmentreferstocariesriskassessmentaswellasthedentalhealthassessmentportionofearlychildhoodhealthassessment.Cariesriskassessment(CRA)referstothedeterminationofthelikelihoodoftheincidenceofcaries.InBChealthauthorities,dentalstaffplayacentralroleincariesriskassessment,whilePublicHealthNursesprovideearlychildhoodhealthassessmentsandmakeappropriatereferralstodentalstaff.


Figure 2. 2007 BC Early Childhood Dental Programs Logic Model


EVALUATION MEASURES AND METHODS

Defining and Measuring Early Childhood CariesResearchershavenotedthatcautionshouldbeexercisedwhencomparingtheprevalenceofearlychildhoodcariesfoundindifferentstudiesbecausedifferentdiagnosticcriteriaareused.30‘TheoverallreportedprevalenceofECCvariesdramaticallydependingoncasedefinition,populationstudied,andresearchmethodsemployed.’31TheAmericanAcademyofPediatricDentistry(AAPD)definesECCas‘theoccurrenceofatleastoneprimarytoothaffectedbydecayinachildunder6yearsofage.32AlthoughtheAAPDclearlydefinesthemeaningofECC,themechanismsfordeterminingthepresenceofECCstillvary.Forinstance,theWorldHealthOrganization’s(WHO’s)standardforsurveyingearlychildhoodcariesistheDMFT/DMFS(Decayed,Missing,orFilledTeethorSurfaces);however,thistypeofdatacollectiontypicallyinvolvesaclinicalsettingandisthusnotalwaysconducivetolargepopulationsurveys,suchastheoneinBC,whichsurveysmorethan35,000childreneachyear.Instead,aBasicScreeningSurvey(BSS)isusedinBCtoassesstheoralhealthstatusofitspopulationofyoungchildren.TheBSShasalsobeenutilizedintheUSasacheckfordecayexperience:33

“For its studies of decay experience in young children, the U.S. federal government…counts children as having decay experience only if they have one or more visible cavities (without radiographs), have one or more visible fillings, or have one or more teeth missing because of decay. White spots, even if readily evident, are not counted…” (p. 31).34

TheBSSprovidesaframeworkforobtainingoralhealthdatathatisinexpensive,easytoimplementandconsistent.35TheinformationgatheredisatalevelconsistentwithmonitoringnationalhealthobjectivesfoundintheUSPublicHealthService’sHealthyPeopledocument.AlthoughthereislittleresearchonthevalidityandreliabilityoftheBSSmeasure,a1994studyof632elementaryschoolchildreninGeorgia,USfoundhighvalidityforcariesandtreatmentneeds(>90%sensitivity,specificity,andpredictivevaluesinasamplehaving30%to40%prevalence).36TheBSShasbeennotedtobeaquickerandmorecost-efficientmethodofcollectingdataonearlychildhoodcariesinlieuofmoreformalepidemiologicalsurveysusingtheDMFT/DMFS.37, 38

AppendixCprovidesabriefsummaryofselectedstudiesofECCprevalencebasedontheBSSinvariouspopulations.AllUSjurisdictionsusedindicatorsandcriteriafromtheBSSmanualdevelopedbytheAssociationofStateandTerritorialDentalDirectors(includingadditionalcodingoptions).39InBC,theBritishColumbia30S.Peressinietal.,“Prevalenceofdentalcariesamong7-and13-year-oldFirstNationschildren,DistrictofManitoulin,Ontario,”J.Can.Dent.Assoc.70,no.6(2004):382. 31BergandSlayton,Early childhood oral health.32AmericanAcademyofPediatricDentistry,“Oralhealthpolicies,”Pediatric Dentistry26,no.7(2004):16-61. 33BCMinistryofHealth,Evidence review: Dental public health(Victoria,BC:BCMinistryofHealth,2006),http://www.vch.ca/media/Evidence_Review_Dental.pdf.34BergandSlayton,Early childhood oral health.35Ibid. 36E.D.Beltrán-Aguilar,D.M.Malvitz,andS.A.Eklund,“Validityoftwomethodsforassessingoralhealthstatusofpopulations,”Journal of Public Health Dentistry57,no.4(1997):206-214.37AssociationofStateandTerritorialDentalDirectors,Basic screening surveys: An approach to monitoring community oral health(Sparks,NV:AssociationofStateandTerritorialDentalDirectors,1999).38E.Beltrán-Aguilaretal.,“Oralhealthsurveillance:Past,present,andfuturechallenges,”Journal of Public Health Dentistry63,no.3(2003):141-149.39AssociationofStateandTerritorialDentalDirectors,Basic screening surveys: An approach to monitoring community oral health.


publichealthdentalprogramsstafffollowascreeningmanual,whichwasdevelopedin1990andlateradaptedbytheBCDentalPublicHealthCommittee(BCDPHC).40 ThismanualcoversindicatorsandcriteriawhichareconsistentwiththeBSSmanual,aswellasadditionaltrainingmaterialsandtopicsrelevanttotheBCcontext(e.g.,self-studysheets,documentationandprivacystandards,regulationofdentalpersonnel,low-costdentalclinics).

The Kindergarten Dental Survey in British Columbia: A Brief OverviewTheKindergartenDentalSurveyisadministeredbypublichealthdentalstaff(registeredDentalHygienistsandCertifiedDentalAssistants)whoperformavisualinspectionofeachkindergartenchild’smouthwithasmalllightandtonguedepressortodeterminethepresenceofobviousorvisibletoothdecay.Dentalprogramstafffollowacalibrationprocesstoensureconsistenttechnique.Theyinspectkindergartenchildren’smouthsforbrokenenamel,existingrestorations,andurgenttreatmentneeds.Aftertheinspection,childrenareclassifiedasbelongingtooneofthefollowingthreeoralhealthoutcomes:

Code 1: No Visible Decay Experience:ChildrenwithNoVisibleDecayorrestorations.

Code 2: No Visible Decay; Has Treatment:ChildrenthathaveNoVisibleDecaybutdohaveexistingrestorations(e.g.,fillingsorcrowns).41

Code 3: Visible Decay:Childrenthathaveobviousdecayasevidencedbybrokenenamel.Shadowingwithoutbrokenenamelisnotconsideredvisibledecay.

Inaddition,afourthcodeexists,whichcanapplytoanyofthedentalcodesabove:

Code 4: Urgent Treatment Needs:Childreninneedofimmediatedentalcare(e.g.,achildwhoisinobviouspainatthetimeofthesurveyorhasobviousvisibleinfectionasevidencedbyanabscess,grossswelling,orthepresenceofpus).

Inotherwords,astudentcanhave‘urgenttreatmentneeds’(Code04)despitehavingnovisibledecay(Code01).Studentswhohavehadprevioustreatment(Code02)orwhohavevisibledecay(Code03)canalsohaveurgenttreatmentneeds(Code04).Numerically,thesumofCodes01to03shouldbeequaltothenumberofkindergartenstudentssurveyed.

BC’sHealthAuthoritiesconductedthefirstfull-scaleimplementationoftheKindergartenDentalSurveyduringthe2006/07schoolyearwithanestimated35,602kindergartenstudents.TheKindergartenDentalSurveywasre-administeredin2009/10withapproximately35,215kindergartenstudentsfrompublic,independentandFirstNationsschoolsonReserve.

Inbothsurveyyears,BC’sKindergartenDentalSurveyreachedapproximately9outof10enrolledstudents.Table1displaysthenumberofstudentssurveyedandenrolledbyhealthauthority(HA)andhealthservicedeliveryarea(HSDA)forBritishColumbiain2006/07and2009/10.

40BritishColumbiaDentalPublicHealthCommittee,Dental Screening Manual,2006.41Notethatduetothenatureofthesurveytooluseditisbecomingincreasinglydifficulttoidentifyallrestoredteeth(e.g.whitecolouredfillings)Wyman,T.(PersonalCommunication,2011).


• NorthernHealthAuthorityshowedthelargestpercentincreaseamongthehealthauthoritiesintermsofsurveycoverage,with91.0%ofkindergartenstudentssurveyedin2006/07and95.3%(+4.3percentagepoints)in2009/10.

• TheNorthernInteriorshowedthelargestpercentincreaseinsurveycoverageamongallhealthservicedeliveryareas(HSDAs).In2006/07,86.5%ofkindergartenstudentsweresurveyed;94.4%weresurveyedin2009/10(+7.8percentagepoints).

HealthAuthorityinformationissummarizedinFigure3below.

Environmental ScanIn2008,aspartofanongoingenvironmentalscanofBCearlychildhooddentalprograms,HELPreviewedthedentalhealthriskassessmenttools,guidelinesusedineachHealthAuthority,aswellasover100HealthAuthorityhandoutsrelatedtooralhealthandnutritionforchildrenunderage6.Fivemaintopicsemergedfromreviewofthecontentofthesematerials:dentalvisits,previous/familytoothdecay,toothbrushingandfluoride,feedingpractices,andsocioeconomicstatus.ConsultationswithdentalstaffwerealsoconductedtoidentifytherangeofdentalhealthriskassessmentstrategiesusedacrossHealthAuthorities.Theinformationgatheredwasusedtoaddressevaluationquestionsrelatedtoprogramactivities,aswellastoinformthedesignoffocusgroupswithpublichealthdentalstaff(forfurtherdetails,seeDentalHealthRiskAssessmentFocusGroupsProvincialAnalysis).

Table 1. BC Kindergarten Dental Survey Coverage for Health Regions by Survey Year Surveyed Enrolled* % SurveyedHA and Health Region 06-07 09-10 06-07 09-10 06-07 09-10Fraser 14,256 13,660 15,502 15,060 92.0 90.7East 2,788 2,649 2,820 2,867 98.9 92.4North 4,775 4,716 5,247 5,189 91.0 90.9South 6,693 6,295 7,435 7,004 90.0 89.9Interior 5,465 5,574 6,016 6,146 90.8 90.7TheKootenays 1,224 1,296 1,370 1,434 89.3 90.4Okanagan 2,543 2,542 2,787 2,769 91.2 91.8TCS 1,698 1,736 1,859 1,943 91.3 89.3Northern 2,769 2,980 3,044 3,126 91.0 95.3Northeast 810 769 853 804 95.0 95.6NorthernInterior 1,306 1,313 1,509 1,391 86.5 94.4Northwest 653 898 682 931 95.7 96.5VancouverCoastal 7,799 7,681 8,468 8,423 92.1 91.2Vancouver 4,072 3,918 4,444 4,400 91.6 89.0Richmond 1,473 1,520 1,600 1,626 92.1 93.5Coastal 2,254 2,243 2,424 2,397 93.0 93.6VancouverIsland 5,313 5,320 5,861 5,922 90.7 89.8South 2,498 2,556 2,746 2,856 91.0 89.5Central 1,825 1,765 2,030 1,979 89.9 89.2North 990 999 1,085 1,087 91.2 91.9

BC(Total) 35,602 35,215 38,891 38,677 91.5 91

*Sourceofenrollmentfigures:BCHealthAuthorities.


Focus Groups with Public Health Dental StaffFocusgroupswereconductedinthesummerof2009withpublichealthdentalstaffacrosstheprovinceinorderto:identifytherangeofdentalhealthriskassessmentstrategiesusedinHealthAuthorities;understandkeybarrierstoprogramreach;andreflectuponkeysuccessfactorsandhowtheprogramscouldbeimproved.ThefocusgroupprocesswasdevelopedincollaborationwithHealthAuthorityrepresentativesandtheBCEarlyChildhoodDentalProgramsEvaluationSubcommittee.Questionsdevelopedforthefocusgroupsparticipantsexploredissuessuchasimplementationofassessmentguidelines,barrierstopublichealthdentalprogramreach,lessonslearned,andregionally-developedquestionsofinterest.

Eightfocusgroupswereconductedwithatotalof61publichealthdentalstaff,representing72%ofpublichealthdentalstaffacrosstheprovince.FromacrossthefiveHealthAuthorities,participantsincluded33DentalHygienists,24CertifiedDentalAssistants,oneDentist,andthreeprogrampartnerstaff(e.g.,FirstNationsHealthStaff).AllparticipantswereknowledgeableinformersduetotheperspectivesgainedfromtheirpersonalexperienceandobservationslivingandworkinginBCandtakingpartinimplementationofaHealthAuthorityearlychildhooddentalprogram.Mostparticipantshadworkedindentalpublichealthformanyyearswhileafewhadonlyrecentlybecomeengagedinpublichealth,andmanyreportedthattheyalsohadexperienceworkinginprivatedentalpractices.Onaverage,participantshad15yearsofdentalpublichealthexperience(rangingfrom0to38years).

Figure 3. BC Kindergarten Dental Survey Coverage by Health Authority


Basedonpriorconsultationwithdentalstaff,focusgroupfacilitatorsfromHELPdevelopedprogramimplementationprocessdiagramsforeachHealthAuthority,whichwerereviewedandrevisedduringthefocusgroups.Eachfocusgroupwastranscribedverbatim.Transcriptswereanalyzedusingconstantcomparativetechniquestocategorizethedataintokeythemes.42Forfurtherdetails,see:DentalHealthRiskAssessmentFocusGroupsProvincialAnalysis.

Provincial and Regional MappingTheKindergartenDentalSurveydatawasalsousedinconjunctionwithdatafromthe2004Taxfilerdataset,the2006CensusandWave3oftheEarlyDevelopmentInstrument(2007-2009)datasetinordertocreateaseriesofprovincialandregionalmapstovisuallyrepresentdentalhealthoutcomes.Theproducedmapstypicallyusedpiechartstoshowthedistributionofkindergartenchildrenfromeachschooldistrictineachofthefourdentaloutcomecategories.Aswell,themapsweretypicallycolour-codedaccordingto‘quintiles’ofvulnerabilityintheprovince.Geocodingwasusedinthemappingprocessbyassigningageographicalcoordinate(latitude-longitude)toanaddress,andthendisplayingtheaddressonamaporusingitinaspatialsearch.ThemappingfeatureoftheevaluationprocessallowedHELPtovisuallydepictregional,schooldistrict,andneighbourhoodvariationindentaldecayforthehealthauthorities.Additionally,HELPwasalsoabletocreateseveralmapsvisuallyrepresentingthecorrelationsbetweenearlychildhoodcariesandseveralsocioeconomicstatusvariables.

42Aqualitativemethod(groundedtheory)wasusedtoanalyzethedata.Thegoalofthistypeofanalysisisnottoconductcountsorquantify;rather,theaimistoprovideadescriptiveaccountofparticipantexperiencesandperspectivesasvoicedthroughthefocusgroups.


EVALUATION FINDINGS

Thefindingsfromtheevaluationprojectareorganizedaccordingtothefouroverarchingevaluationquestionsandinturnthefollowingfourkeythemes:

1. EarlyChildhoodDentalHealthSurveillance2. RiskAssessment3. HealthPromotionandPreventionStrategies;and4. BuildingPartnerships.


EARLY CHILDHOOD DENTAL HEALTH SURVEILLANCE

Thefirstkeythemeofsurveillanceisrelatedtotheinitialevaluationframeworkquestion:

1. Is the oral health of young children improving? By community? By vulnerability?Todetermineiftheoralhealthofyoungchildren(age4-6)inBCisimproving,wepresentfindingsfromthe2006/07and2009/10KindergartenDentalSurveysfortheprovince,healthauthorities,healthregions(healthservicedeliveryareas)andHELPneighbourhoods(seeAppendixDformoreinformationon“HELPneighbourhoods”)withrespecttothefollowing:

a. EarlyChildhoodCaries(ECC)rates,definedasthepercentofkindergartenchildrensurveyedwithcurrentorpreviousdecay,andchangesintheseratesovertime.43

b. Socioeconomicinfluencesonearlychildhoodoralhealth,includingOn-andOff-Diagonalrelationships(i.e.,neighbourhoodswithhighECCdespitehavinghighsocioeconomicstandingorlow-socioeconomicneighbourhoodswithlowratesofECC).

c. TherelationshipbetweenECCanddevelopmentalvulnerabilityasmeasuredbytheEDI(EarlyDevelopmentInstrument).

43Pleasenotethatinthecontextofthisproject,wearereferringtoCodes02+03asindicatorsofdecayexperience.Thesecodesreflectthedentaldecaythatisvisiblethroughavisualcheckratherthanthedentaldecay(observableandnon-observable)thatwouldbedetectablethroughmoresensitiveclinicalassessmenttools.

Accordingtoanalysisoftheresultsfromthe2006/07and2009/10KindergartenDentalSurveys,theoralhealthofyoungchildreninBCappearstohaveimprovedoverall,andregionaldifferenceswereidentifiedintermsofdentalhealth.

• In2006/07,61.1%ofkindergartenstudentssurveyedinBChadnovisibledecay(Code01);in2009/10,thepercentageincreasedto63.3%,whichis3.3%abovetheprovincialtargetof60%.

• 942fewerkindergartenchildrenwereidentifiedashavingvisibledentaldecayin2009/10thanin2006/07inBC.387fewerchildrenweresurveyedin2009/10thanin2006/07.

• ThegreatestimprovementswereobservedintheInterior,wherethe%VisibleDentalDecay(Code02+03)decreasedfrom40.2%in2006/07to36.1%in2009/10,andinVancouverCoastalhealthauthority,whichexperienceda5.8%decrease(40.9%in2006/07to35.1%in2009/10).

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Early Childhood Caries in British Columbia’s Health Authorities and Health Regions Overall,theoralhealthofkindergartenchildrenshowedslightimprovementsbetweensurveyyears.In2006/07,61.1%ofstudentssurveyedhadnovisibledecay(Code01);in2009/10,thepercentageincreasedto63.3%,whichis3.3%abovetheprovincialtargetof60%.

• ThegreatestimprovementswereobservedintheInterior,wherethepercentCode01increasedfrom59.8%in2006/07to63.9%in2009/10,andinVancouverCoastalHA,whichexperienced5.8%increase(59.1%in2006/07to64.9%in2009/10).

• AmongHSDAs,thepercentCode01intheNorthwestwas49.3%in2006/07and53.7%in2009/10;intheCoastalRegionofVCHA,72.4%ofchildrenhadnovisibledecayin2006/07and78.8%werecaries-freein2009/10.

• Thehighestratesintermsoffillingsorotherrestorations(Code02)werefoundinFraserEastin2006/07(26.6%)andtheNorthwestin2009/10(24.8%);andthelowestratesforCode02acrosssurveyyearswerefoundinVancouverCoastalHSDA(17.7%in2006/07and14.1%in2009/10).

• VancouverCoastalHSDAhadthelowestratesforCode03whereasThompsonCaribooShuswap,RichmondandNorthwestHSDAsshowedrelativelyhighratesofcurrentdecay(>25%)in2006/07andretainedthehighestratesofcurrentdecayrelativetootherHSDAsin2009/10;ratesofcurrentvisibledecayforallthreeareasdroppedslightlyin2009/10toapproximately22%.Table2.1presentsthepercentofstudentssurveyedbyCodeforHAsandHSDAsin2006/07and2009/10.Anadditionalcolumnispresentedinthetablecalled“%VisibleDentalDecay,”whichisthesumofCodes02and03(includingCode04s)ortheinverseofCode01.This

• Dentaloutcomesofchildrendifferbygeographiclocation(e.g.,byneighbourhood):- TsawwassenNorthexperiencedthelargestincreaseinvisibledentaldecaybetweensurveyyearsfrom10.96%in2006/07to46.77%in2009/10.

- ThevisibledentaldecayrateoftheOkanagan’sSouthWestneighbourhoodwascutinhalfbetweenKindergartenDentalSurveyyears.

- 72neighbourhoodsdecreasedinvisibledentaldecayand47neighbourhoodsincreasedinvisibledentaldecayfrom2006/07to2009/10.

- 10neighbourhoodsexperienceda25%decreaseinthenumberofchildrenidentifiedashavingvisibledentaldecay.

- 4neighbourhoodsexperienceda25%increaseinthenumberofchildrenidentifiedashavingvisibledentaldecay.

Andbythesocioeconomicstatusoftheneighbourhood:- Childrenfromsocioeconomicallydisadvantagedneighbourhoodstendtohavehigherratesofvisibledentaldecaythanthoseinmoreadvantagedsocioeconomicneighbourhoods;however,thehighestabsolutenumberofchildrenwithvisibledentaldecayresidesinmid-levelsocioeconomicneighbourhoods.

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variabledefinesourmaindentaloutcomemeasureinthestatisticalanalysispresentedtofollow.Figure4presentsHealthAuthorityratesforeachofthedentalcodesaswell.

• Table2.2presentskindergartendentalhealthoutcomedatabycodeforthe2006/07surveyyear,andTable2.3presentsthisinformationfor2009/10.

• Inaddition,thetablespresentthenumberofstudentswithnodentaldecay(Code01),whichareestimatesbasedonthenumberofstudentssurveyedinthehealthregion.Table2.4presentsthepercentagechangebetweensurveyyearsalongwiththenumberofkindergartenchildren(K)affectedbythischange.

• Overall,theprovincialrateofkindergartenvisibledentaldecay(Code02+03)droppedbetweensurveyyearsby2.2percentagepoints,from38.9%in2006/07(seeTable2.1or2.2)to36.7%in2009/10(seeTable2.1or2.3).

• Intermsofthenumberofkindergartenchildrenaffectedbythispercentagechange,942fewerkindergartenchildrenwereidentifiedashavingvisibledentaldecayin2009/10thanin2006/07intheprovinceofBC.

Table 2.1. Kindergarten Dental Health Outcomes by Survey Year for Health Regions

HA and Health Region

% Code 01 % Code 02 % Code 03 % Code 04

% Visible Dental Decay (Code 02 + 03)

06-07 09-10 06-07 09-10 06-07 09-10 06-07 09-70 06-07 09-10

Fraser 61.6 62.3 22.5 20.3 16.0 17.4 1.6 2.2 38.4 37.7

FraserEast 62.4 63.3 26.4 23.2 11.2 13.5 0.6 0.6 37.6 36.7

FraserNorth 65.8 65.0 23.2 21.1 11.0 13.9 1.5 1.9 34.2 35.0

FraserSouth 58.1 59.8 20.3 18.6 21.5 21.6 2.2 3.1 41.9 40.2

Interior 59.8 63.9 20.7 18.2 19.5 17.9 3.5 3.1 40.2 36.1

TheKootenays 60.6 67.7 19.9 16.1 19.5 16.1 4.2 2.8 39.4 32.3

Okanagan 64.1 66.8 20.1 16.9 15.8 16.3 2.6 3.1 35.9 33.2

TCS 52.7 56.8 22.3 21.8 25.0 21.4 4.4 3.2 47.3 43.2

Northern 58.8 58.8 18.5 21.4 22.7 19.7 3.5 3.2 41.2 41.1

Northeast 58.9 58.0 19.3 21.5 21.9 20.4 2.8 2.3 41.1 41.9

NorthernInterior 63.6 62.8 18.2 19.0 18.2 18.1 2.6 3.7 36.4 37.2

Northwest 49.3 53.7 17.9 24.8 32.8 21.5 6.0 3.0 50.7 46.3

VancouverCoastal 59.1 64.9 20.5 18.3 20.4 16.8 1.8 1.3 40.9 35.1

Vancouver 54.7 59.9 22.4 19.8 22.9 20.3 2.0 1.5 45.3 40.1

Richmond 51 57.1 19.5 20.7 29.5 22.2 3.7 2.0 49.0 42.9

Coastal 72.4 78.8 17.7 14.1 9.9 7.1 0.3 0.4 27.6 21.2

VancouverIsland 65.1 65.5 23.6 20.7 11.3 13.8 1.2 1.1 34.9 34.5

SouthVancouverIsland 69.1 69.1 21.5 18.2 9.4 12.7 1.8 1.0 30.9 30.9

CentralVancouverIsland 60.9 62.0 26.6 23 12.5 14.9 0.5 1.4 39.1 37.9

NorthVancouverIsland 62.4 62.3 23.6 22.8 13.9 14.7 0.9 0.8 37.6 37.5

BC(Total) 61.1 63.3 21.6 19.7 17.3 17.0 2.0 2.1 38.9 36.7

Note:Cellvaluesarecolourcodedtocorrespondtotherangesofvaluesaspresentedintheattachedmappingpackage.Seelegendformoredetails.


Figure 4. Kindergarten Dental Health Outcomes by Health Authority

Table 2.2. Kindergarten Dental Health Outcomes and Number of Kindergarten Students Surveyed in 2006/07 by Health Region

Health Authority & Health Service Delivery Area

Code 01 Code 02 Code 03 Code 04% Visible Dental Decay (Code 02 + 03)

% K % K % K % K % KFraser 61.6 8775 22.5 3204 16.0 2277 1.6 234 38.4 5481

FraserEast 62.4 1740 26.4 737 11.2 311 0.6 16 37.6 1048

FraserNorth 65.8 3144 23.2 1106 11.0 525 1.5 71 34.2 1631

FraserSouth 58.1 3891 20.3 1361 21.5 1441 2.2 147 41.9 2802

Interior 59.8 3267 20.7 1132 19.5 1066 3.5 192 40.2 2198

TheKootenays 60.6 742 19.9 243 19.5 239 4.2 52 39.4 482

Okanagan 64.1 1631 20.1 510 15.8 402 2.6 66 35.9 912

TCS 52.7 894 22.3 379 25.0 425 4.4 74 47.3 804

Northern 58.8 1629 18.5 511 22.7 629 3.5 96 41.2 1140

Northeast 58.9 477 19.3 156 21.9 177 2.8 23 41.1 333

NorthernInterior 63.6 830 18.2 238 18.2 238 2.6 34 36.4 476

Northwest 49.3 322 17.9 117 32.8 214 6.0 39 50.7 331

VancouverCoastal 59.1 4610 20.5 1599 20.4 1590 1.8 143 40.9 3189

Vancouver 54.7 2228 22.4 912 22.9 932 2.0 81 45.3 1844

Richmond 51.0 751 19.5 287 29.5 435 3.7 55 49.0 722

Coastal 72.4 1631 17.7 400 9.9 223 0.3 7 27.6 623

VancouverIsland 65.1 3457 23.6 1255 11.3 601 1.2 62 34.9 1856SouthVancouverIsland 69.1 1727 21.5 536 9.4 235 1.8 44 30.9 771

CentralVancouverIsland 60.9 1112 26.6 485 12.5 228 0.5 9 39.1 713

NorthVancouverIsland 62.4 618 23.6 234 13.9 138 0.9 9 37.6 372

BC(Total) 61.1 21738 21.6 7701 17.3 6163 2.0 727 38.9 13864


Early Childhood Caries by School District and HELP Neighbourhoods HELPpreviouslyworkedcloselywithrepresentativesfromseveralBCcommunitiestoinformthecreationofHELPneighbourhoodswithgeographicboundariesdemarcatedbynaturalboundariesasperceivedbytheneighbourhood’sresidents.Severalfactorswereconsideredwhendefiningneighbourhoodboundariesincluding:

• naturalsocialandeconomicdivisionsincommunities.• naturalorotherphysicalboundariessuchasravines,waterways,majorhighways.

• localmunicipalboundaries(e.g.,municipalities,regionaldistricts).• schoolcatchmentareas.• neighbourhoodassociationboundaries.

Asaresultofthisprocess,HELPidentified478neighbourhoodsinBC,whichareanticipatedtoaccountforthelong-termanticipatedgrowthanddeclineinthepopulationpatternsofcommunities(seeAppendixDforfurtherdiscussionaboutthecreationofHELPneighbourhoods).

UsingschooldistrictsandHELPneighbourhoodsasboundaries,aMappingPackagewascreatedtopresentkindergartendentalsurveyoutcomesovertime(i.e.,in

Table 2.3. Kindergarten Dental Health Outcomes and Number of Kindergarten Students Surveyed in 2009/10 by Health Region

Health Authority & Health Service Delivery Area

Code 01 Code 02 Code 03 Code 04% VisibleDental Decay (Code 02 + 03)

% K % K % K % K % KFraser 62.3 8508 20.3 2777 17.4 2375 2.2 301 37.7 5152

FraserEast 63.3 1677 23.2 614 13.5 358 0.6 17 36.7 972

FraserNorth 65.0 3066 21.1 993 13.9 657 1.9 91 35.0 1650

FraserSouth 59.8 3765 18.6 1170 21.6 1360 3.1 193 40.2 2530

Interior 63.9 3562 18.2 1017 17.9 995 3.1 171 36.1 2012

TheKootenays 67.7 878 16.1 209 16.1 209 2.8 36 32.3 418

Okanagan 66.8 1698 16.9 430 16.3 414 3.1 80 33.2 844

TCS 56.8 986 21.8 378 21.4 372 3.2 55 43.2 750

Northern 58.8 1753 21.4 638 19.7 588 3.2 94 41.1 1226

Northeast 58.0 446 21.5 165 20.4 157 2.3 18 41.9 322

NorthernInterior 62.8 825 19.0 250 18.1 238 3.7 49 37.2 488

Northwest 53.7 482 24.8 223 21.5 193 3.0 27 46.3 416

VancouverCoastal 64.9 4983 18.3 1408 16.8 1290 1.3 99 35.1 2698

Vancouver 59.9 2347 19.8 777 20.3 794 1.5 58 40.1 1571

Richmond 57.1 868 20.7 315 22.2 337 2.0 31 42.9 652

Coastal 78.8 1768 14.1 316 7.1 159 0.4 10 21.2 475

VancouverIsland 65.5 3483 20.7 1099 13.8 735 1.1 58 34.5 1834

SouthVancouverIsland 69.1 1766 18.2 465 12.7 325 1.0 26 30.9 790

CentralVancouverIsland 62.0 1095 23.0 406 14.9 263 1.4 24 37.9 669

NorthVancouverIsland 62.3 622 22.8 228 14.7 147 0.8 8 37.5 375

BC(Total) 63.3 22289 19.7 6939 17.0 5983 2.1 723 36.7 12922


2006/07and2009/10)andinrelationtosocioeconomicstatusfor59schooldistrictsand437HELPneighbourhoods.Figure5.1belowpresentsoneoftheprovincialmapscreatedtodepictdentaldecayforkindergartenstudents(byschooldistrict)in2009/10.

TheMappingPackage(seeAttached)presentsneighbourhood-leveldentalhealthoutcomesalongwithdemographicandsocioeconomicvariables.Threetypesofmapsarepresentedinthepackage:interactivemaps,provincialmaps,andhealthauthoritymaps:

1. Theinteractivemapsallowtheusertogenerateamaptailoredtoherorhisneedsusingoptionallayerssuchashealthauthorityboundaries,citynames,neighbourhoodnames,roads,socioeconomicstatusanddemographics,andearlychilddevelopmentdata;thesemapsenableuserstozoomintotheneighbourhoodlevel,orzoomouttotheprovinciallevel;

2. Theprovincialmapsshowdentaldecaybyschooldistrictateachofthefourcodelevels,aswellasthechangebetweenthe2006/07to2009/10data;andHealthauthorityspecificmapsshowdentaldecaybyneighbourhood,witheachofthefourcodelevels,aswellasthechangebetweenthe2006/07to2009/10data.

Table 2.4. Change in Kindergarten Dental Health Outcomes and Number of Kindergarten Students Affected by Health Region Health Authority & Health Service Delivery Area

Code 01 Code 02 Code 03 Code 04% Visible Dental Decay(Code 02 + 03)

% K % K % K % K % KFraser +0.7 -267 -2.2 -427 +1.4 +98 +0.6 +67 -0.7 -329

FraserEast +0.9 -63 -3.2 -123 +2.3 +47 0 +1 -0.9 -76

FraserNorth -0.8 -78 -2.1 -113 +2.9 +132 +0.4 +20 +0.8 +19

FraserSouth +1.7 -126 -1.7 -191 +0.1 -81 +0.9 +46 -1.7 -272

Interior +4.1 +295 -2.5 -115 -1.6 -71 -0.4 -21 -4.1 -186

TheKootenays +7.1 +136 -3.8 -34 -3.4 -30 -1.4 -16 -7.1 -64

Okanagan +2.7 +67 -3.2 -80 +0.5 +12 +0.5 +14 -2.7 -68

TCS +4.1 +92 -0.5 -1 -3.6 -53 -1.2 -19 -4.1 -54

Northern 0 +124 +2.9 127 -3.0 -41 -0.3 -2 -0.1 +86

Northeast -0.9 -31 +2.2 +9 -1.5 -20 -0.5 -5 +0.8 -11

NorthernInterior -0.8 -5 +0.8 +12 -0.1 0 +1.1 +15 +0.8 +12

Northwest +4.4 +160 +6.9 106 -11.3 -21 -3.0 -12 -4.4 +85

VancouverCoastal +5.8 +373 -2.2 -191 -3.6 -300 -0.5 -44 -5.8 -491

Vancouver +5.2 +119 -2.6 -135 -2.6 -138 -0.5 -23 -5.2 -273

Richmond +6.1 +117 +1.2 +28 -7.3 -98 -1.7 -24 -6.1 -70

Coastal +6.4 +137 -3.6 -84 -2.8 -64 +0.1 +3 -6.4 -148

VancouverIsland +0.4 +26 -2.9 -156 +2.5 +134 -0.1 -4 -0.4 -22

SouthVancouverIsland 0 +39 -3.3 -71 +3.3 +90 -0.8 -18 0 +19

CentralVancouverIsland +1.1 -17 -3.6 -79 +2.4 +35 +0.9 +15 -1.2 -44

NorthVancouverIsland -0.1 -4 -0.8 -6 +0.8 +9 -0.1 -1 -0.1 +3

BC(Total) 2.2 551 -1.9 -762 -0.3 -180 0.1 -4 -2.2 -942


Theprovincialandneighbourhood-levelmapsareaccompaniedbycomprehensivedatatablesthatpresentschooldistrict-andneighbourhood-leveldentalhealthoutcomes,indicatorsofsocioeconomicstatusandearlychilddevelopmentasmeasuredbytheEDIduringthe2007/08and2008/09schoolyears(Wave3).Thetablesincludedinthepackageincludeavariablecalled“%VisibleDentalDecayChange,”whichmeasuresthepercentincreaseordecreaseintherateofvisibledentaldecayfrom2006/07to2009/10.Thisvariablecanbeusedasageneralindicatoroftheoralhealthofyoungchildreninthecommunity(i.e.,neighbourhood).Table3.1presentsneighbourhoodswith25%orgreaterchangeinvisibledentaldecayratesacrosssurveyyears.Table3.2presentsschooldistrictswithconsistentdentaldecayratesacrosssurveyyears.

Figure 5.1. Map of British Columbia Depicting the Percentage of Kindergarten Students Identified as Having Visible Dental Decay in 2009/10 by School District.


TheinteractivemapsoftheMappingPackagecontainseveralinterestingfindingsthatmightnototherwisebenoticedinthedatatables.Forinstance,someneighborhoodsappeartobeoutliersincomparisonwithadjacentneighbourhoodsintermsofdentalhealth.Examplesofthese“outliers”includethefollowing:

Table 3.1. Neighbourhoods With a 25% or Greater Change in % Visible Dental Decay Between Survey Years

HA Neighbourhood Name

% VisibleDental Decay (06/07)

% Visible Dental Decay (09/10)*

% Visible Dental Decay Change

SES Index (2006)

% Vulnerable on EDI (07/08 & 08/09)

FHA TsawwassenNorth 11.0 46.8 35.8 1.0 17.5FHA Abbotsford 67.7 41.9 -25.8 -1.3 38.1IHA Salmo 61.9 35.0 -26.9 0.2 32.7IHA Rossland/Warfield 47.2 20.0 -27.2 1.3 8.9IHA EastBoundary 52.0 24.3 -27.7 0.7 27.9IHA Enderby 50.0 22.2 -27.8 -0.2 25.6IHA SouthWest 67.7 32.3 -35.4 -0.4 28.0NHA NorthPeaceRural-East 28.6 55.6 27.0 1.2 41.5VCHA Norgate 45.5 20.0 -25.5 -0.7 30.6VCHA Hamilton 61.1 32.8 -28.3 0.4 22.6VIHA Gabriola 50.0 25.0 -25.0 0.0 NAVIHA OuterGulfIslands 20.0 53.3 33.3 0.6 NAVIHA ComoxWest 46.7 19.2 -27.5 0.5 NAVIHA SouthWellington-Cassidy 30.8 62.5 31.7 -0.8 NA

Table 3.2. School Districts with Consistent Visible Dental Decay Rates Across Survey Years

HA SD Neighbourhood Name% Visible Dental Decay (06/07)

% Code 01 (06/07)

% Visible Dental Decay (09/10)

% Code 01 (09/10)

IHA 19 Revelstoke-Central 47.1 52.9 42.3 57.7IHA 19 Revelstoke-Northwest 61.5 38.5 42.9 57.1IHA 19 Revelstoke-South 53.3 46.7 66.7 33.3IHA 58 Merritt 54.2 45.8 48.0 52.0IHA 58 Princeton 63.3 36.7 45.8 54.2IHA 74 GoldTrailWest 64.3 35.7 62.0 38.0IHA 74 GoldTrailEast NA NA 64.0 36.0NHA 52 PrinceRupert-Centre 52.5 47.5 60.6 39.4NHA 52 PrinceRupert-CowBay NA NA NA NA

NHA 52 PrinceRupert-South/Ferry 52.7 47.3 43.5 56.5

NHA 52 PrinceRupert-SealCove 68.4 31.6 53.9 46.2

NHA 52 NorthCoastalCommunities 50.0 50.0 71.4 28.6

VCHA 45 HorseshoeBay-Bow.Island 23.8 76.2 14.4 85.6

VCHA 45 Dundarave 24.3 75.7 15.8 84.2

VCHA 45 Ambleside-BritProperties 23.9 76.1 16.3 83.7


• TsawwassenNorthwith46.8%visibledentaldecay,butadjacenttoTsawwassenSouthwith23.3%visibledentaldecayandDeltaRuralwith23.7%visibledentaldecay(seeFigure5.2).

Figure 5.2. Tsawwassen North (VCHA)

• SunValleywith62.1%visibledentaldecay,butsurroundedbycommunitiessuchasPittMeadowswith25.9%visibledentaldecay,LincolnParkwith31.3%,ImperialParkwith37.5%,Central/MaryHillwith30.8%,Citadelheightswith22.8%,CastleParkwith24.1%andImperialParkwith37.5%(seeFigure5.3).

Figure 5.3. Sun Valley (FHA)

• Rocklandwith51.6%visibledentaldecay,butadjacenttoQuinsam-Strathconawith31.0%visibledentaldecay,CampbellRiverSouthwith24.8%andShelterPointwith28.1%(seeFigure5.4).

Figure 5.4.Rockland (VIHA)

• DawsonCreekCentrewith28.6%visibledentaldecay,butadjacenttocommunitiesDawsonCreekSouthwith52.4%visibledentaldecay,SouthPeaceRuralwith51.6%andDawsonCreekNorthwith42.2%(seeFigure5.5).

Figure 5.5. Dawson Creek Centre (NHA)


Socioeconomic Influences of Early Childhood Oral Health in BCTheBCDentalProgramsEvaluationSubcommitteeprovidedinputontheselectionofvariablesfortheanalysisofsocioeconomicstatus(SES)anddentalhealthoutcomes.BasedontheSubcommittee’sfeedback,thefollowingsocioeconomicanddemographicvariablesfromthe2001/2006Censusand2004TaxFilerdatasetswereselectedforanalysis:

1. UnionorProfessionalMembership:Percentofpopulationpayingunionorprofessionaldues,withchildrenunderage6.

2. NotFluentinEnglish/French:PercentofpopulationthatdoesnotspeakeitherEnglishorFrenchfluently.

3. NoHighSchoolEducation:Percentofpopulationbetweentheageof25and64thatdoesnothaveahighschooldegree.

4. Low-Income:Percentofindividualslivinginhouseholdsbelowthelow-incomecutoff(LICO).Thisvariabledoesnotincludetheworkingpoororindividualswithlowerincomeslivingabovethesocialassistanceline.

5. Lone-ParentFamilies:Percentofcensusfamiliesheadedbyasingleparent.6. ResidentialMobility:Percentofpopulationthatmovedresidencesinthepastyear.

7. AboriginalPopulation:PercentofpopulationthatisAboriginal(self-identified).

Table4presentsdescriptivestatistics(samplesize,means,standarddeviations)fortheprovinceandhealthauthoritiesonthesevenvariablesselectedforanalysisbytheDentalEvaluationSubcommittee.Somekeyfindingsfromthetableareasfollows:

• UnionandprofessionalmembershipissimilaracrossHAs,withtheexceptionbeinginVCHAwhere32.6%oftaxfilerspayduescomparedtotheprovincialaverageof35.1%.

• VCHAalsohasthehighestratesofnon-fluencyinEnglishorFrench(4.3%)andpersonsbelowthelow-incomecutoff(16.5%vs.12.1%fortheprovince).

• Morethanoneinfiveadults(age25-64)residinginNHAhavenotcompletedhighschool(22.0%)and17.3%ofhouseholdsareledbyasingleparent.

Figure6belowpresentsprovincialandregionalvariationsrelatedtothesevenSubcommittee-chosenvariables.ItshouldbemadeclearthatofthesevenvariablespresentedinFigure6,onlyunionand/orprofessionalmembershipisconsidereda‘protective’factorintermsofSES;allothermeasuresarerelatedto‘risk’factors(i.e.,indicatorsoflowSES).

Table 4. Socioeconomic Status (SES) and Demographic Information for Province and HAs

Fraser Interior Northern Vancouver Coastal

Vancouver Island BC (Total)

Subcommittee SES Variables M SD M SD M SD M SD M SD M SDUnionorProfessionalMembership 35.5 7.8 34.6 8.8 36.4 10.1 32.6 8.1 36.1 8.8 35.1 8.6

NotFluentinEnglishorFrench 3.7 3.7 0.4 0.6 0.4 0.5 4.3 4.9 0.4 0.4 2.1 3.4

NoHighSchool 13.1 6.1 15 5.6 22 5.9 8.3 6.4 13.0 6.0 13.7 6.9Low-Income 14.1 6.8 9.3 3.8 9.7 5.6 16.5 8.4 9.6 5.1 12.1 6.7LoneParenthood 14.8 4.2 14 4.5 17.3 5.9 15.3 4.0 15.7 5.6 15.1 4.8Mobility 15.9 4.7 16.7 3.9 17.2 5.6 16.7 5.7 16.7 4.6 16.5 4.8AboriginalIdentity 2.9 2.8 6.5 6.8 20.4 17.9 3.5 8.6 7.0 6.9 6.4 9.5

Neigbourhoods 164 103 49 66 90 472


HELPalsocreatedaSESindexalongwithseveralsubcomponents(e.g.,Wealth,Education,Unemployment,etc.)inrelationtoearlychilddevelopment.DatafortheHELPSESIndexwasderivedfromthe2006Censusand2004TaxFilerdatasets.Thenamesofthesecomponents,andtheindividualvariablesincludedineachofthem,canbefoundinAppendixE.TheappendixalsopresentsinformationonhowtheHELPSESindexwascreated.

Table5displaysvisibledentaldecayratesforfiveSESlevels,thenumberofstudentssurveyedwithinHELPSEScategoriesandthenumberofstudentswithdentaldecaybyeachsocioeconomicclassification.UsingHELP’sSESindex,wefoundthatdentaldecayratesremainedrelativelystableacrosssurveyyearsforalllevelsofSES;however,dentaldecayratesvariedgreatlydependingontheSESoftheneighbourhood:

• Approximately5in10childrenfromlowSESneighbourhoodsexperiencedentaldecay

• Atleastone-thirdofchildrenfrommoderate-levelSESneighbourhoods(whichreflectsthemajorityofBCneighbourhoods)experiencedentaldecay.

• Approximately3in10childrenfromhighSESneighbourhoodsexperiencedentaldecay.

HELPexaminedindividualcorrelationsbetweeneachofthesevenSESvariableschosenbytheDentalEvaluationSubcommitteeandearlychildhooddentalhealthoutcomes.Table6.1presentstheresultsofthecorrelationanalysis,whicharesummarizedasfollows:

Figure 6. SES and Demographic Measures for Province and Health Authorities


• Inboth2006/07and2009/10,the%NoHighSchoolformsthestrongestrelationshipwith%VisibleDentalDecay.

• Unionandprofessionalmembershipistheonly“protective”factoramongthegroupofSESvariables.

• WithrespecttotheHELPSESIndexthestrongestrelationshipswiththe%VisibleDentalDecaywerewealthandunemployment.

Correlationswerealsocomputedbetweenthe%VisibleDentalDecayandtheHELPSESIndex,includingeachofitselevensubcomponents(seeAppendixE).Theresultsoftheanalysis,whicharesummarizedbelow,canbefoundinTable6.2.• TheoverallSESIndexwasabetterpredictorofdentalhealththananyindividualSEScomponent(e.g.,Wealth,Unemployment,etc.).

• TheWealthsubcomponentoftheSESIndexhadthestrongestcorrelationwiththe%VisibleDentalDecayin2006/07and2009/10.Thisleadsustospeculatethatasacommunity’swealthincreases,theirrateofdentaldecaywilldecline.

• Unemploymentwasanotherstrongcorrelateofdentaldecay,butinthiscaseasariskfactor.Astheunemploymentrateofcommunitiesrise,sodoestheirrateofdentaldecay.

Table 5. Visible Dental Decay (Code 02 + 03) Rates by Neighbourhood Socioeconomic Status (based on overall HELP SES Index)HELP SES Index (2006)

% Visible Dental Decay in 2006/07


HELP SES Index Categories

M SD Neigh-bourhoods

Students Surveyed*

Students w/

Decay*M SD Neigh-

bouhoodsStudents

Surveyed*

Students w/

Decay*

LowSES 49.6 11.1 89 7,661 3,800 48.3 12.4 94 7,552 3,648

ModeratelyLowSES 41.7 10.3 88 6,495 2,708 39.9 10.6 91 6,603 2,635

ModerateSES 37.8 10.5 86 6,548 2,475 35.6 10.1 94 6,915 2,462

ModeratelyHighSES 33.9 8.4 88 6,600 2,237 33.4 10.1 93 6,713 2,242

HighSES 30.9 8.8 87 6,422 1,984 29.9 9.9 93 6,804 2,034

TOTAL 38.8 11.8 438 33,726 13,086 37.4 12.4 465 34,587 12,936

Notes:LowSES=bottom20thpercentileofneighbourhoodsinBC(intermsofSES)…HighSES=top20thpercentileofneighbourhoodsinBC.M=Mean(Average);SD=StandardDeviation;Neighborhoods=numberofHELPneighborhoodsassignedtoSEScategory.*Thenumberofkindergartenstudentssurveyedandwithdecayisanunderestimateduetosuppression.

Table 6.1. Correlations between Subcommittee SES/Demographic Measures and % Visible Dental Decay (Code 02 + 03)

Correlations (r)Visible Dental Decay 06/07 (n = 438)

Visible Dental Decay 09/10 (n = 464)

SubcommitteeSESvariables:

Union/Prof.Membership -.397 -.448

NotFluentinEnglish/French .330 .304

NoHighSchool .546 .577

Low-Income .437 .356

LoneParentFamilies .363 .364

ResidentialMobility .228 .166

AboriginalIdentity .337 .432

Note:Allcorrelationcoefficientsinthetablearesignificantatp<.01.


TofurtherillustratetherelationshipbetweenSESanddentaldecayacrosssurveyyears,Figure7presentsascatterplotshowingthegeneralpatternoftherelationshipbetweenHELP’sSESIndex(2006)andpercentdentaldecaybykindergartendentalsurveyyear.• Inbothsurveyyears,asthesocioeconomicstatusofcommunitiesincreases(movingfromlefttorightontheX-axis),thepercentdentaldecaysteadilydeclines.

• ThestrengthoftherelationshipbetweenSESandvisibledentaldecayissimilaracrossbothsurveyyears;70–75%

Figure 7. Visible Dental Decay Rates by HELP SES Percentile

Table 6.2. Correlations between HELP SES Index and Subcomponents and % Visible Dental Decay (Code 02 + 03)

Correlations (r)



HELPSESIndex(2006) -.565 -.538

Wealth -.541 -.551

Unemployment .500 .512

ResidentialStability -.272 -.210

Poverty .290 .278

LoneParents .433 .455

HousingDensity .152 .103

LanguageandImmigration .234 .185

WomeninManufacturing -.413 -.360

Education -.383 -.429

SocialAssistance -.446 -.394MedianGov’tTransfers -.474 -.471



ofthevarianceinpredictingvisibledentaldecayratesacrosssurveyyearsisunexplainedbySES.Thismeansthatthereareothercommunity-levelfactorsthatinfluencevisibledentaldecayrates,whicharenotincludedinouranalysis.

HELPextendedthecorrelationalanalysisbyconductingaseriesofMultipleRegressionAnalyses,whichprovidetheaddedbenefitofexaminingtherelationshipbetweenvisibledentaldecayandseveralindicatorsofSESsimultaneously.ThisallowsforafullerpicturetobegleanedabouttherelationshipbetweenSESanddentaldecaybecausesevendifferentindicatorsofSES,aschosenbytheDentalEvaluationSubcommittee,wereincludedinthesameanalysis.

TheresultsoftheanalysesusingthesevenSubcommittee-chosenSESvariablesarepresentedinTable7.1.AppendixDpresentsinformationonhowtointerprettheresultsoftheRegressionAnalysis;someofthekeyfindingsarepresentedbelow:

• Accordingtotheanalyses,thepercentofadults(age25-64)inthecommunitywith“NoHighSchool”(i.e.,the%adultswhodidnotcompletehighschool)istheriskfactorthatbestpredictsyoungchildren’soralhealth,explaininghalfofthevarianceinvisibledentaldecayratesin2006/07andtwo-fifthsofthevariancein2009/10.

• Low-incomeisthesecondstrongestriskfactorintermsofthe%VisibleDentalDecayin2006/07,butthisrelationshipissomewhatweakenedin2009/10.

• UnionorprofessionalmembershipandNon-FluencyinEnglishorFrencharenotstrongpredictorsofearlychildhooddentaldecayin2006/07,buttheyarein2009/10.

• Loneparenthoodandresidentialmobilityarealsonotstrongpredictorsoforalhealthoutcomesofyoungchildren.

Table 7.1. Regression Analysis for SES (Subcommittee) and % Visible Dental Decay (Code 02 + 03)

Dependent Variables

Subcommittee SES/ Demographic Variables

Visible Dental Decay 06/07

VisibleDental Decay 09/10

Union/Prof.Membershipb=-.029 b=-.189*s.e.=.065 s.e.=.063

1.888 12.554

NotFluentinEnglish/French

b=.240 b=.722**s.e.=.196 s.e.=.190

5.304 12.876

NoHighSchoolb=.704** b=.582**s.e.=.092 s.e.=.086

50.430 40.103

Low-Incomeb=.578** b=.251*s.e.=.120 s.e.=.118

32.705 10.288

LoneParentFamiliesb=-.051 b=.082s.e.=.131 s.e.=.130

-1.672 2.470

ResidentialMobilityb=.069 b=-.076

s.e.=.105 s.e.=.1061.452 -1.043

AboriginalIdentityb=.178* b=.320**s.e.=.074 s.e.=.065

9.860 22.818

(Constant)b=21.468** b=29.511**s.e.=3.766 s.e.=3.639

N(neighbourhoods) 438 464

F 47.904** 57.367**

R2 .438 .468

Std. Error of the Estimate 8.932 9.095

**p<.01;*p<.05;Dp<.10.ValuesinboldareImportanceScores.


• CommunitieswithlargernumbersofAboriginalpeoplestendtohavehigherratesofearlychildhoodcaries.

Table 7.2. Regression Analysis for SES (HELP) and % Visible Dental Decay (Code 02 + 03) Dependent Variables

HELP SES Index and Scales Visible Dental Decay 06/07 Visible Dental Decay 09/10

HELPSESIndex(2006)b=-6.685** b=-6.665** s.e.=.467 s.e.=.486 100.000 100.000

Wealth(MainModel) b=-4.621** b=-4.711** s.e.=.667 s.e.=.682

48.330 47.500

Education(excludeWealth) b=-4.968** b=-5.875**

s.e.=.717 s.e.=.714

37.504 44.961

SocialAssistance(excludeWealth)

b=-3.779** b=-2.268**

s.e.=.785 s.e.=.768

34.171 18.690

MedianGov’tTransfers(excludeWealth)

b=-4.486** b=-4.038** s.e.=.767 s.e.=.749

41.088 36.432

Unemployment b=3.110** b=3.088** s.e.=.655 s.e.=.624

26.330 27.714

ResidentialStability b=-.581 b=-1.780** s.e.=.559 s.e.=.571

-2.956 -6.663

Poverty b=.116 b=.164 s.e.=.507 s.e.=.516

0.671 -0.829

LoneParents b=.821 b=1.928** s.e.=.692 s.e.=.687

6.554 16.175

LanguageandImmigration b=3.181** b=3.776**

s.e.=.634 s.e.=.652

14.180 12.450

WomeninManufacturing b=-.797 b=-.526

s.e.=.538 s.e.=.544

6.724 3.643

(Constant)b=39.694** b=29.511** b=38.267** b=39.932**

s.e.=.470 s.e.=3.639 s.e.=.488 s.e.=.624

N(neighbourhoods) 439 439 465 465

F 204.657** 47.130** 188.175** 50.520**

R2 .319 .434 .289 .436

Std. Error of the estimate 9.764 8.967 10.439 9.356

**p<.01;*p<.05;Dp<.10.NumbersinboldareImportanceScores.


WithregardtotheHELPSESindexandsubcomponents,severalregressionanalyseswereruntopredictthe%VisibleDentalDecayin2006/07andin2009/10.Table7.2presentstheresultsoftheseanalyses(seeAppendixDforinformationoninterpretingregressionanalyses).Thekeyfindingsareasfollows:

• Aswasfoundinthecorrelationalanalysis,“Wealth”wasthesocioeconomicprotectivefactorthatmoststronglypredictedtheoralhealthoutcomesofyoungchildren,explainingnearlyhalfofthevarianceinvisibledentaldecayratesacrossbothsurveyyears.

• EducationandMedianGovernmentTransferswerealsostrongprotectivefactorsinpredictingthe%VisibleDentalDecay,butthesesubcomponentsoftheHELPSESIndexwerehighlyrelatedtoWealth(seeAppendixDforexplanation).Inotherwords,these3factorshaveanoverlappinginfluenceontheoralhealthofcommunities.

• Unemploymentwasthesolesocioeconomicriskfactorthatconsistentlypredicteddentaldecayratesinboth2006/07and2009/10.

Tables8.1and8.2presentImportanceScoresalongwiththepatternoftherelationshipforeachSESvariable(Subcommittee-chosenandHELPSESIndexwithsubcomponents)andtherateofvisibledentaldecay.

• HigherImportanceScores(positivevalues)representstrongerrelationshipswiththe%VisibleDentalDecayrelativetootherSESvariables.

• ImportancescoresfortheSESindexinthesemodels=100%,becauseitisthesolevariablepredictingdentaldecayinthemodels(seefirstoftwocolumnsundereachanalysisofthe%VisibleDentalDecayin2006/07and2009/10).

• Inbothsurveyyears,aone-unitincreaseintheHELPSESIndexcorrespondstonearlya7-percentreductionintherateofvisibledentaldecay.Aone-unitincreaseintheSESIndexroughlycorrespondstoapercentileincreasefrom50th(provincialaverage)tothe79thpercentile.

Table 8.1. Subcommittee SES/Demographic Importance Scores in Predicting the % Visible Dental Decay (Code 02 + 03)



Importance Score

Pattern of Relationship

Importance Score


Subcommittee SES variables

Union/Prof.Membership 1.9 Decay 12.5* Decay

NotFluentinEnglish/French 5.3 Decay 12.9** Decay

NoHighSchool 50.4** Decay 40.1** Decay

Low-Income 32.7** Decay 10.3* Decay

LoneParentFamilies -1.7 Decay+ 2.5 Decay

ResidentialMobility 1.5 Decay -1.0 Decay+

AboriginalIdentity 9.9* Decay 22.8** Decay

Note:ImportanceScoresmaynotaddupto100duetoroundingerror.*p<.05;**p<.01.+Counterintuitivefinding:therelationshipwith%VisibleDentalDecayformedtheoppositerelationshipfromwhatwasexpected(hencethenegativeimportancescore).


On- and Off-DiagonalsAnexploratoryanalysiswasconductedtoidentify‘on’and‘off’diagonalneighbourhoods.On-diagonalneighbourhoodsareneighbourhoodsthathaveexpectedoutcomesintermsofSESanddentalhealth.

Moreformally,on-diagonalscanbedefinedas:

• HighSESneighbourhoodswithlowratesofvisibledentaldecayinboth2006/07and2009/10;or

• LowSESneighbourhoodswithhighratesofvisibledentaldecayinbothsurveyyears.

Off-diagonalsareneighbourhoodsthathaveeitherworsethanexpectedorbetterthanexpecteddentaloutcomeswithregardtotheirsocioeconomicstatus.Off-diagonalscanbedefinedas:

• HighSESneighbourhoodswithhighratesofvisibledentaldecayinboth2006/07and2009/10;or

• LowSESneighbourhoodswithlowratesofvisibledentaldecayinbothsurveyyears.

Table9presentsthenumberandpercentofonandoff-diagonalneighbourhoodsidentifiedacrosssurveyyears.Somekeyfindingsareasfollows:

• 277neighbourhoods(outof444neighbourhoods)wereidentifiedason-diagonalsin2006/07andagainin2009/10.Theseneighbourhoodshadratesofvisibledentaldecaythatwereasexpectedbasedontheirsocioeconomicstatus(i.e.,highervisibledentaldecayrateswereassociatedwithlowersocioeconomicstandings).Forinformationonhowon-diagonal

Table 8.2. HELP SES Index and Component Importance Scores in Predicting the % Visible Dental Decay (Code 02 + 03)



Importance Score


Importance Score


HELP SES Index 100.0** Decay 100.0** Decay

Wealth(MainModel) 48.3** Decay 47.5** Decay

Unemployment 26.3** Decay 27.7** Decay

ResidentialStability -3.0 Decay+ -6.7** Decay+

Poverty 0.7 Decay -0.8 Decay+

LoneParents 6.6 Decay 16.2** Decay

LanguageandImmigration 14.2** Decay 12.5** Decay

WomeninManufacturing 6.7 Decay 3.6 Decay

Note:ImportanceScoresmaynotaddupto100duetoroundingerror.ImportanceScoresforEducation,SocialAssistanceandMedianGovernmentTransfersarenotincludedinthemainmodelduetocollinearity.(i.e.,theanalysisincludingEducationexcludesWealth,SocialAssistance,andMedianGovernmentTransfersfromthemodel).*p<.05;**p<.01.+Counterintuitivefinding:therelationshipwith%VisibleDentalDecayformedtheoppositerelationshipfromwhatwasexpected(hencethenegativeimportancescore).


scoresarecalculated,pleaseseeForer(2007).

• Intotal,100off-diagonalswereidentifiedeitherin2006/07andin2009/10,50betterthanexpectedand50worsethanexpected.Alistoftheseneighbourhoodsbysurveyyearisprovidedintheexcelspreadsheetattachment.Forinformationonhowoff-diagonalscoresarecalculated,pleaseseeForer(2007).

• Inordertobeconsideredaconsistentoff-diagonal,theneighbourhoodmustbeanoff-diagonalinbothKindergartenDentalSurveyyears.Intotal,30neighbourhoodswereidentifiedasconsistentoff-diagonals:14betterthanexpected(e.g.,FairviewinVancouver)and16worsethanexpected(e.g.,Rosedale/ChilliwackEastinFraserEast).

Table 9. Summary of Neighbourhood On/Off-Diagonals (SESDental)#

NeighbourhoodsValid % of

Neighborhoods

PersistentOn-Diagonal 277 62.4%

Off-Diagonalin06/07only 67 15.1%

Off-Diagonalin09/10only 67 15.1%Off-Diagonalin06/07&09/10 33 7.4%

PersistentOff-Diagonalsin06/07&09/10 30 6.8%

Table 10. Neighbourhood Off-Diagonals (SESDental)

Surveyed Dental Decay CHANGE SES

Health Region Neighbourhood 06-07 09-10 06-07 09-10 06/07-09/10 Percentile

Bette

r Tha

n Ex

pect

ed

FraserN. Metrotown 98 104 36.7 41.4 4.6 0Okanagan KLO/Casorso 70 81 21.4 21.0 -0.4 42Okanagan CentralWest 26 15 34.6 26.7 -8.0 15Okanagan NortheastRutland 52 49 32.7 22.5 -10.2 21NorthShore Delbrook 80 102 17.5 15.7 -1.8 93NorthShore MosquitoCreek 97 92 27.8 19.6 -8.3 36NorthShore Blueridge 58 69 13.8 13.0 -0.8 67NorthShore Dundarave 103 95 24.3 15.8 -8.5 52

NorthShore Ambleside-BritProperties 251 221 23.9 16.3 -7.6 44

Vancouver UniversityLands 74 93 39.2 31.2 -8.0 6Vancouver Fairview 121 122 26.5 16.4 -10.1 31N.Van.Island Glacierview/Vanier 42 78 26.2 23.1 -3.1 44S.Van.Island Fairfield 144 154 18.8 22.1 3.3 58S.Van.Island JamesBay 54 33 24.1 27.3 3.2 20

Wor

se T

han

Expe

cted

FraserE. Rosedale/ChilliwackEast 110 138 45.5 45.7 0.2 89

FraserN. DeerLake 22 29 63.6 55.2 -8.5 33FraserS. Bridgeview 15 17 60.0 70.6 10.6 26TCS Revelstoke-South 15 12 53.3 66.7 13.3 96

TCS WilliamsLake-Downtown 58 83 63.8 65.1 1.3 13

TCS Dallas/MonteCreek 89 101 52.8 49.5 -3.3 76TCS GoldTrailWest 42 50 64.3 62.0 -2.3 72TCS Shuswap 40 26 52.5 46.2 -6.4 71E.Kootenay Creston 60 105 51.7 50.5 -1.2 48KootenayB. Robson/Thrums 26 11 50.0 45.5 -4.6 75Northeast SouthPeaceRural 26 31 61.5 51.6 -9.9 92Northeast DawsonCreekSouth 49 42 49.0 52.4 3.4 50Northwest Hazeltons 50 80 74.0 73.8 -0.3 1C.Van.Island SouthNanaimo 78 71 59.0 60.6 1.6 9C.Van.Island CobbleHill 31 23 41.9 56.5 14.6 92

N.Van.Island CampbellRiver-Centre 21 27 66.7 63.0 -3.7 13


Table10presentsdataonthe30identifiedoff-diagonalneighbourhoods.Thecorrespondingneighbourhood-levelmapsforhealthauthoritiesalsoidentifytheseneighbourhoods.Off-diagonalsserveasagoodstartingpointtoidentifyuniquecaseswheredentalprogramsareworkingand,alternatively,wheremoreresourcesmaybeneededthroughouttheprovince.

Visible Dental Decay Rates and Early Child Development Indicators Inthissection,wepresenttheanalysisofkindergartenvisibledentaldecayratesandearlychilddevelopmentoutcomesinBC,asmeasuredbytheEarlyDevelopmentInstrument(EDI).Theapproachtoanalyzeearlychildhooddentalhealthdatawithrespecttoearlychilddevelopmentoutcomesisreflectiveofaholisticviewthatoralhealthisnotmutuallyexclusivefromachild’soverallhealthanddevelopmentmoregenerally.Forexample,itisanticipatedthatpopulationsconsideredathighriskintermsoftheirgeneralhealthandwell-beingmaydisproportionatelyexperiencenotonlyhigherratesofvisibledentaldecaybutalsohigherratesofdevelopmentalvulnerability.Analysisofpopulation-levelearlychilddevelopmentdatawithkindergartenvisibledentaldecaydatacouldyieldnewinformationabouttheextentthattherearecommonriskfactors,suchasthesocioeconomicstatusanddemographicsofaneighbourhood,thatmaydifferentiallyinfluenceyoungchildren’soralhealthandoveralldevelopmentovertimeandacrossgeographicareas.

TheEDIisusedinBCtounderstandthevulnerabilityofthepopulationofyoungchildren.Measuringchildren’sdevelopmentatschoolentryisimportantbecauseitreflectsthequalityofchildren’searlyexperiences.TheEDIisaholisticmeasureofchildren’sdevelopmentandprovidesmeasurementonthesefivedistinctscales:

1. Physicalhealthandwell-being2. Socialcompetence3. Emotionalmaturity4. Languageandcognitivedevelopment5. Communicationskillsandgeneralknowledge

KindergartenteacherscompleteanEDIchecklistforeachchildintheirclassaftertheyhaveknowntheirstudentsforseveralmonths.Allteachersundergostandardizedtrainingintheadministrationoftheinstrument.FormorediscussionoftheEDI,pleaseseeAppendixD.Table 11. EDI (Wave 3) Vulnerability Rates (%) for Province and HAs

EDI Wave 3 (2007-09) Fraser Interior Northern Vancouver Coastal

Vancouver Island BC (Total)

% Vulnerable by Scale M SD M SD M SD M SD M SD M SDPhysicalHealth&Well-being 11.0 6.7 10.2 6.8 15.9 9.0 11.3 7.6 10.9 6.5 11.4 7.2

SocialCompetence 12.4 6.9 9.9 6.0 14.7 9.9 13.4 6.2 12.3 7.7 12.2 7.3EmotionalMaturity 11.3 6.3 11.5 7.3 12.8 6.0 13.0 6.2 11.7 7.2 11.8 6.7

Language&CognitiveDevelopment 9.9 6.2 8.6 6.0 15.0 8.7 9.0 6.3 9.8 5.5 10.0 6.6

CommunicationSkills&GeneralKnowledge 13.3 7.0 10.0 6.5 14.0 9.4 14.1 8.6 10.9 5.9 12.3 7.4

OneorMoreScales 27.8 11.1 24.6 10.9 33.3 13.1 29.4 11.3 26.3 10.0 27.6 11.4

Note:M=mean;SD=standarddeviation.


Table11presentsdescriptivestatistics(samplesize,means,standarddeviations)fortheprovinceandfivehealthauthoritiesforeachofthefiveEDIsubscales,includingtheoverallmeasureofvulnerability(vulnerableononeormorescales).ThedataarefromWave3oftheEDI,whichwasadministeredinthe2007/08and2008/09schoolyears.

AsaninitialtestoftherelationshipbetweenEDIandtheoralhealthofyoungchildren,correlationswerecomputedbetweenthe%VisibleDentalDecayin2006/07andsixindicatorsofearlychilddevelopment(asmeasuredbyWave3oftheEDI).TheresultsofthecorrelationanalysisarepresentedinTable12.

MultipleRegressionAnalyseswerealsoconductedinwhichthe%VisibleDentalDecayandtheHELPSESIndexwerejointlyusedtopredicteachmeasureofEDIinWave3(e.g.,%childrenvulnerableintermsofphysicalhealthandwell-being).TheresultsoftheseanalysesarepresentedinTable13andsummarizedbelow:

• Theoralhealthofyoungchildren,asmeasuredbythe%ofkindergartenchildrenwithvisibledentaldecay,isasignificantpredictorofearlychild

Table 12. Correlations between EDI Vulnerability Rates (Wave 3) and % Visible Dental Decay (Code 02 + 03)

Correlations (Pearson’s r) Visible dental Decay 06/07 (n = 439)

EDIVulnerability(Wave3): .398

PhysicalHealth&Well-being .335

SocialCompetence .280

EmotionalMaturity .222

Language&CognitiveDevelopment .366

CommunicationSkills&GeneralKnowledge .376


Table 13. Regression Analysis for % Visible Dental Decay (Code 02 + 03) and EDI Vulnerability Rates (Wave 3) Dependent Variables: % Vulnerable on EDI (Wave 3)

Independent Variables Physical Social Emotional Language Commun-

ication One or More Scales

VisibleDentalDecay06/07

b=.066* b=.027 b=.017 b=.083** b=.031 b=.092*

s.e.=.030 s.e.=.032 s.e.=.030 s.e.=.028 s.e.=.029 s.e.=.044

17.203 6.185 5.262 24.287 4.950 10.966

HELPSESIndex(2006)

b=-2.735** b=-5.457** b=-2.251** b=-2.415** b=-4.327** b=-6.003**

s.e.=.356 s.e.=.549 s.e.=.360 s.e.=.326 s.e.=.343 s.e.=.527

82.797 93.815 94.738 75.713 95.050 89.034

(Constant)b=8.786** b=

11.395**b=

11.314** b=6.807** b=11.702**

b=24.447**

s.e.=1.229 s.e.=1.309 s.e.=1.242 s.e.=1.127 s.e.=1.186 s.e.=1.819

N(neighbour-hoods)

439 439 439 439 439 439

F 60.796** 53.897** 31.904** 65.326** 128.445** 118.147**

R2 .218 .198 .128 .231 .371 .351

Std. Error of the Estimate

6.135 6.535 6.201 5.626 5.921 9.082

**p<.01;*p<.05;Dp<.10.NumbersinboldareImportanceScores.


developmentintermsof(1)physicalhealthandwell-being,(2)languageandcognitivedevelopment,and(3)overalldevelopmentalvulnerability(i.e.,vulnerabilityononeormorescalesoftheEDI).

• TheserelationshipswerefoundaftercontrollingfortheeffectsofSES.Relativetothesocioeconomicstatusofthechild’scommunity,however,theoralhealthofyoungchildrenisarelativelyweakpredictorofearlychilddevelopment.

SummaryOverall,thesefindingssuggest:

• Dentaloutcomesofchildrendifferbygeographiclocationandsocioeconomicstatusoftheneighbourhood.

• Althoughthepercentagechangeinvisibledentaldecayratesataprovinciallevelbetween2006/07and2009/10wassmall,ratesofchangedifferedgreatlydependingupontheneighbourhood.

• Childrenfromsocioeconomicallydisadvantagedneighbourhoodstendtohavehigherratesofvisibledentaldecaythanthoseinmoreadvantagedneighbourhoods.Theproportionofchildrenaffectedishighestinthelowestsocioeconomicstatusneighbourhoods(i.e.,1forevery2childrenhasvisibledentaldecay);however,intermsofnumbersofchildrenwithvisibledentaldecay,themajorityofchildrenwithvisibledentaldecayresideinneighbourhoodswithmid-levelcategoriesofsocioeconomicstatus.

• Thereisamoderatelevelofconsistencybetweenratesofvulnerability,asmeasuredbytheEDI,andratesofvisibledentaldecay,atleastforthe2006/07dentalsurveydataset.

• Visibledentaldecaydoesnotappeartomakeastrong,uniquecontributionoverandabovesocioeconomicfactorsinpredictingratesofearlychildhoodvulnerability.


RISK ASSESSMENT

2. Are the current dental health risk assessment/screen guidelines implemented as intended?

Withinfocusgroupdiscussions,dentalstaffconsistentlyreportedthattheywerefamiliarwithregion-specificprotocolsandguidelinesfordentalhealthriskassessments.Ingeneral,staffineachHealthAuthoritystatedthatdentalhealthriskassessmentguidelineswerebeingimplementedasintendedandthatthetoolsweresimpletouseaspartoftheestablished,routineprocedures.Thereweresomevariationsamongdentalhealthriskassessmentimplementationprotocolsandguidelines,suchaswhichassessmenttoolsareused,aswellastheproceduresforaskingparentsquestions,identifyingandclassifyingrisklevels,andfollowing-upwithfamilies.

2i. What standardized dental health risk assessment tool/questions should be used with children aged 0-5 (including kindergarten entry) in BC?In2007/2008HELPundertookaCariesRiskAssessment44ToolDevelopmentproject,whichincludedareviewoftheliteratureandbest-practiceswithinandoutsideBC,consultationswithpublichealthdentalstaff,andrecommendationsfromtheBCEarlyChildhoodDentalProgramsEvaluationSubcommittee.Asaresultofthisprocess,HELPwasabletodistillfivekeythemesthatcutacrosstheliteratureaswellasthedifferenttoolsandguidelinesusedinhealthauthorities:dentistvisits,signsofdecay,toothbrushingandfluoride,feedingpractices,barrierstoaccess(seeAppendixFformoredetails).Thesethemesweredrawnupontoproposeseveralriskassessmentquestionsthatcouldbeconsideredwithanyfuturedevelopmentofthetool(Forfurtherinformationaboutthesequestions,pleaseseetheProvincialCariesRiskAssessment(CRA)ToolDevelopmentandValidationTemplate).

Inconsideringanyrevisionstotheassessmenttool,itmaybeusefultonotethatinaScottishstudyof1500one-year-olds,thetwomostsignificantriskindicatorsforthechildhavingatleastthreecariousteethattheageoffourwere(1)livinginsocialhousing,and(2)thehealthvisitor’ssubjectiveopinionon“Isthischildathighrisk

44Inthisevaluationproject,dental health risk assessmentreferstocaries risk assessmentaswellasthedentalhealthassessmentportionofanearlychildhoodhealthassessment.Caries risk assessment(CRA)referstothedeterminationofthelikelihoodoftheincidenceofcaries.InBChealthauthorities,dentalstaffplayacentralroleincariesriskassessment,whilePublicHealthNursesprovideearlychildhoodhealthassessmentsandreferralstodentalstaff.

Perhaps we should look at adding additional questions regarding…accessibility issues and other factors that influence caries risk?”

Focus Group Participant, NHA

Avarietyoftools,guidelines,andfollowuptechniquesarecurrentlybeingusedacrosshealthauthorities.

Additionally,dentalstaffconsistentlyreportedthatriskassessments/screeningguidelineswerebeingimplementedasintended,andweresimpletouse.K

EY F

IND

ING


oforfromcaries”(yes/no)(sensitivity=65%,specificity=69%).45IntheScottishNationalClinicGuidelineforthePreventionandManagementofToothDecayinthePreschoolChild,itisstatedthatcariesriskassessmentwouldbeappropriateforusebybothdentalandnon-dentalpersonal,andwouldbeappropriateinaprimarycaresetting.46Extrapolatingfromtheavailableevidence,theguidelinerecommendsthat“specialistcommunitypublichealthnursesandchildhealthcareprofessionalscouldconsidercarryingoutacariesriskassessmentofchildrenintheirfirstyearasapartofthechild’soverallhealthassessment.”

2ii. At what age(s) should these be administered?Atthetimeofevaluation,healthauthoritieswerescreeningchildrenatdiverseages.Insomehealthauthoritiesaquestionnairewasadministeredat12-month-oldChildHealthClinics(CHCs).Othershealthauthoritiesoffertheriskassessmentincommunitysettingsandatthehealthunitforchildren0-4yearsold.FraserHealthAuthorityalsoofferedintegratedscreeningprogramsfor18-month-oldchildrenincareaswellas3-year-oldchildrenatselectedcommunitysites.VancouverIslandHealthAuthorityintegrateddentalhealth-relatedquestionsintothehealthassessmentbyPublicHealthNurses(PHNs)ateachCHC,fromthe2-monththroughthe24-monthvisit.

Inthefocusgroups,opinionsontheidealageatwhichriskassessmentsshouldbeadministeredrangedfrom6months-oldto18months-old.Generally,itwasbelievedthatassessmentatanearlierageprovidesmoretimelypreventiveinterventions.Itprovidesopportunitiesforpublichealthstafftoworkwiththecaregiversorparentsandalsoenablesthechildtobecomefamiliarwithoralhealthexaminations.Theliteraturerecommendsthatcariesriskassessmentsbeadministerednolaterthan12months-old,47, 48withthecaveatthatthefieldofcariesriskassessmentisrelativelynew,49andthattherearemultiplepopulationfactorstoconsiderinprogramplanning(includingsocioeconomicstatus,languagediversity,etc).50

2iii. Who should administer the dental health risk assessment?Avarietyofhealthauthoritystaffadministereddentalhealthriskassessmentsatthetimeofevaluation.Insomehealthauthorities,healthunitvolunteers,clerksorPHNshandedoutapaper-basedquestionnairetoparents.Inotherhealthauthorities,healthunitswithdentalstaffin-house(andusuallyservingsmallerpopulations),aface-to-facedialoguewithparentsmayhavetakenplace.

Aspartofthe2007/08CRAToolDevelopmentprocess,membersoftheDentalEvaluationSubcommitteerecommendedthatifwrittensimply,thestandardizedCRAcouldbeusedbypublichealthdentalpersonnel,includingCertifiedDental

45HeatherBallantyne-MacRitchie,“ApartnershipbetweenhealthvisitorsanddentiststoidentifyhighcariesriskScottishpre-schoolchildren”(PhDThesis,UniversityofDundee,2000).46ScottishIntercollegiateGuidelinesNetwork,Prevention and management of dental decay in the pre-school child: A national clinical guideline(Edinburgh:NationalHealthServicesQualityImprovementScotland,2005).47F.Ramos-Gomez,S.Gansky,andJ.Featherstone,“CariesRiskAssessmentAppropriatefortheAge1Visit(InfantsandToddlers),”Canadian Dental Association Journal35,no.10(2007):687-702.48AmericanAcademyofPediatricDentistryCouncilonClinicalAffairs,“Policyonuseofacaries-riskassessmenttool(CAT)forinfants,children,andadolescents.”49RocioQuiñonezetal.,“Chapter8:Caries-riskassessment,”inEarly childhood oral health(Ames,Iowa:Wiley-Blackwell,2009),170-197.50AssociationofStateandTerritorialDentalDirectors,Research Brief: Fluoride Varnish: an Evidence-Based Approach(Sparks,NV:AssociationofStateandTerritorialDentalDirectors,2007).


Assistants,DentalHygienists,andnon-dentalpublichealthstaff.Itwassuggestedthatwherefeasible,dentalstaffwouldadministerriskassessmentssincetheycouldimmediatelyprovidefollow-up.Ifnodentalstaffwereavailable,non-dentalpublichealthstaff(e.g.,clericalstafforvolunteers)couldadministerthequestionnaireandsubmitthecompletedformstodentalstaffforfollow-up.

2iv. What guidelines and follow-up procedures should be used?AvarietyofguidelineswerebeingusedacrossBCatthetimeoftheevaluation:aclassificationgrid,counselingnotes,healthauthority-specificprotocols,PHNpracticeguidelines.Avarietyoffollowuppracticeswerealsoused,includingon-sitefluoridevarnish,distributionofpamphlets,mailingtoothpaste,andphoningfamiliestoofferfluoridevarnish.InVIHA,familieswerereferredtodentalstaffforcariesriskassessmentifdentalriskfactorsorconcernswereidentifiedduringtheHealthCheckorPHNscreening.Althoughnotbrushingtwicedailyisconsidered“highrisk”insomeareasand“mediumrisk”inothers,thisriskfactorconsistentlydeterminedreferraltothefluoridevarnishprogramacrossallfivehealthauthorities.Ultimately,allguidelinesandfollowupproceduresincludedcontactbymailorphonewithanofferoffluoridevarnishforchildrenassessedashighrisk(and/orrecommendationtoseeadentistfortreatmentasneeded).

Withregardstotheformatofguidelinesandprocedurestobeused,HELPrecommendsthattheMinistryofHealthconsiderdevelopingstandardizedguidelinesandfollowupprocedures(seeRecommendationssectionforfurtherdetails).Aspartofthe2007/08CRAToolDevelopmentprocess,HELPdevelopedaquestionnairetogatherhealthauthoritystaffperspectivesonwhatguidelinesandfollow-upproceduresshouldbeused(e.g.,contentandtypesofguidelines,documentation,preventivestrategiesbyrisklevel,mandatoryversussuggestedfollow-up).Theadministrationofthequestionnairewasdiscontinuedinordertofocustheevaluationontheimplementationoftheexistingdentalhealthriskassessmentprograms.

Contentareasforconsiderationthatstemfromfocusgroupdiscussionsandtheliteratureinclude:

1. FluorideVarnish• Anyprotocolontheapplicationoffluoridevarnishshouldbebasedonriskassessment.51

• Forpredominatelyhigh-riskpopulations(e.g.,peoplewithlowsocio-economicstatus,newimmigrantsandrefugees,allFirstNationsandInuitchildren),fluoridevarnishshouldbeappliedtwiceayear,unlesstheindividualhasnoriskofcaries,asindicatedbypastandcurrentcarieshistory.52

• Giventhatthereisgoodevidenceofthecomplementaryeffectivenessofsealantsandvarnish,aswellastoothbrushingandnutritionalcounseling,oralhealthcareprogramsshouldincludeasmanycomplementarypreventivestrategiesasfeasible.(seealso:Crall,200753).54

• Populationfactorstoconsiderinfluoridevarnishprogramplanninginclude

51A.AzarpazhoohandP.A.Main,“Fluoridevarnishinthepreventionofdentalcariesinchildrenandadolescents:asystematicreview,”Journal (Canadian Dental Association)74,no.1(2008):73-79.52Ibid.53JamesJCrall,“Rethinkingprevention,”Pediatric Dentistry28,no.2(2006):96-101;discussion192-198.54AzarpazhoohandMain,“Fluoridevarnishinthepreventionofdentalcariesinchildrenandadolescents.”


availabilityofdentalcareandproportionofthepopulationwho1)arelowSES,2)areanethnicminority,3)speakEnglishasasecondlanguage,4)arehomeless,5)havelimitededucation,6)havespecialhealthcareneeds,7)havehighcariesincidenceandprevalenceratesoradvanceddisease,and8)lackaccesstofluoridatedwater.55

2. Supportingfamiliesinaccessingtreatmentservices56

• Recommendvisitstodentists.• Maintainlistsofdentistsandaccessibilityinformation(e.g.,acceptingnewpatients,wheelchairaccessible,acceptsFirstNationsNon-InsuredHealthBenefits,acceptsHealthyKidsBenefits).

• Informfamiliesthatdentalofficesmayrequirepaymentattimeofserviceandsuggestthattheyaskinadvanceofdentistvisitswhetherornotpaymentisrequired,therebyhelpingthefamilytobeawareofanychallengestheymayencounteratthedentaloffice.

3. Modesoffollow-upcontact• Considermorepersonalizedfollow-upprocedures.Focusgroupfindingssuggestthatthatfollow-upphonecallsmaybemoreeffectivethanlettersinexpandingfluoridevarnishcoverage(althoughphoningallfamiliesmaybemorecostlyinurbancentresthanruralareas).Follow-upphonecallsprovidedapointofcontactinruralareaswheredentalstaffcouldnotattendCHCsandhadlimitedinteractionwithparents.Participantsacrosstheprovincementionedthatphonecallsworkedwellwithsomevulnerablepopulations.

• Researchindicatesthattelephonecontact,althoughcostly,ismoreeffectivethanletterstoincreasevaccinationrates.57Researchalsoindicatesthatrecallandremindersystemscanhave“spillovereffects”inincreasingpreventivecareandprimarycarevisits.58

• Whereappropriateandconvenientforfamilies,dentalstaffcouldusetextmessagingtoreducethecostofcommunicationforfamilies,particularlyyoungerfamilieswithlowerincomes.

2v. To what extent does the dental health risk assessment/screening reach young children?Electronicchildhealthrecordswerenotavailableforanalysis,andsotheactualnumberofchildrenreceivingthedentalhealthriskassessmentisunknown.Inthefourhealthauthoritiesthatprovidedentalhealthriskassessmentat12-monthimmunizationclinics,dentalstaffreportedthattheywerenotreachingfamiliesthatdonotaccess12-monthimmunizationsthroughpublichealth.About35%ofimmunizationsinBCareprovidedbyphysicians(and90%inVancouverandRichmond).59Also,BCimmunizationcoverageratesdonotincludeFirstNationsandInuitchildrenlivingonreservewhereimmunizationisdeliveredbyBandNursesorbyFirstNationsandInuitHealth.

55AssociationofStateandTerritorialDentalDirectors,Research Brief: Fluoride Varnish: an Evidence-Based Approach.56ThiscomponentisincludedinthePopulationHealthandWellnessServicePlan2007/2008.57V.J.JacobsonandP.Szilagyi,“Patientreminderandpatientrecallsystemstoimproveimmunizationrates,”Cochrane Database of Systematic Reviews(Online),no.3(2005):CD003941.58LanceE.Rodewaldetal.,“ARandomizedStudyofTrackingWithOutreachandProviderPromptingtoImproveImmunizationCoverageandPrimaryCare,”Pediatrics103,no.1(1999):31-38.59BCCentreforDiseaseControl,ImmunizationinBritishColumbia,2006-2007(Vancouver,BC:BCCentreforDiseaseControl,2009).


Inregionsthatprovidedriskassessmentincommunitysites,dentalstaffexpressedconcernthattheprogramwasnotreachingthepopulationsthatcouldmostbenefit.Onespeculationmadewasthatthosefamilieswithat-homechildcare(e.g.,providedbyextendedfamilymemberssuchasgrandparentsoraunts),wouldbedisproportionatelyexcludedfromtheprogram’sreach:

“I think we missed a lot of young families at home, that are at home, and aren’t attending groups. That’s where something like an intensive home visiting program [could be useful] ... where the Public Health Nurse is really connected to the family, and brings in the dental component as needed.”

2vi. To what extent does the program identify a broad spectrum of children at risk for caries?Dentalstaffdescribedarangeofdemographicgroupswhooftendonotaccesspublichealthservices,andthereforedonotreceiveinformationaboutdentalhealthprogramsorkeyoralhealthmessaging.Assuch,focusgroupparticipantsfeltthatthesegroupswereathigherriskfordevelopingcariesandmightnotbeaccessingthepreventiveservicesofferedbydentalpublichealth.Whendiscussingthespecificdemographicgroupswhowereparticularlyhard-to-reach,dentalstaffprimarilyreferredto:familieswithlowincome,lone-parentfamilies,familiesresidinginruralorremotelocations,recentimmigrantfamilies,familiesofAboriginaldescent,andfamilieswithspecialneeds.Resultsfromthe2009/10KindergartenDentalSurveycorroboratethedentalstaff’sidentificationoftheabovementioneddemographicgroups,withparticularlyhighimportancescores,attheneighbourhood-level,forareaswithhigherproportionsofindividualswithnohighschoolgraduation(accountingfor40.1%ofvariabilityinkindergartendentaldecay,ofAboriginalidentity(22.8%),notfluentinEnglish(12.9%),andwithlowincome(10.3%).ResultsforAboriginalchildrenshowthat28.5%ofAboriginalkindergarten-agedchildrenhaduntreatedvisibledecay,comparedto16.2%ofnon-Aboriginalchildren(and34.5%ofFirstNationschildrenattendingFirstNationsschoolsonreserve).60Takentogether,thesefindingsunderscoretheneedforearlychildhoodpreventiveservicestobetailoredforpopulationsofconcern.

2vii. For those eligible children who dental public health is not reaching, what are the barriers?

OneofthebarrierstoprogramreachthatwasmentionedinrelationtotheHealthAuthoritytargetnumbersforassessmentwasstaffworkloadssuchthatmanagerstendedtofocusoncommunitysitesknowntoprovideeasyaccesstochildren.Asoneparticipantstated:

60BCMinistryofHealthServices,Dental Survey of Aboriginal Kindergarten-Aged Children 2009-2010: A Provincial and First Nations School Analysis(Victoria,BC:BritishColumbiaMinistryofHealthandServices,2011).

Themostcommonlyreferencedbarrierstoaccessingpreventativedentalcarewerefamilies’overridingdailystressors,lackoftransportation,lack/expenseoftelephone,languagebarriers,distrustofpublichealthprofessionals.

KEY

FIN

DIN

G


“[managers might say], ‘oh I know that preschool over there, I know I can get my numbers over there, so let’s go there.’ ...So, it often wasn’t a really high risk group or really vulnerable population we were reaching, because it was sort of the pathway of least resistance in a period of time that they had to reach this goal [of reaching a certain number of children].”

Intermsofbarrierstohealthcareaccessforfamilies,focusgroupdiscussionswerelargelyconsistentwithCanadianOralHealthStrategyrecommendationsforim-provingsocial/culturalaccesstooralhealth(i.e.,accesstooralhealthcareinacomfortablesettingwheretheclientcanfeelateasefromacultural,social,andlinguisticpointofview).61Dentalstaffdescribedmultipleintercon-nectedbarriersthatcancreateaccessissuestooralhealthcare,includingoverridingdailystressors,lackoftransportation,lack/ex-penseoftelephone,languagebarriers,adistrustofhealthprofes-sionals,andlimitstotheFirstNa-tionsHealthBenefitprogram.Barriersarediscussedbelowinfurtherdetail.

Overriding stressors:familiesmayoftengivepreventivedentalhealthconcernsalowprioritystatuswhenjuxtaposedwithmoreimmediatedailyneeds,suchasobtainingfood,workingirregularhours,copingwithdomesticviolence,addressinglanguagebarriers,orperhapsattendingmoreimportantappointments,suchasthosewithsocialworkers.

Transportation:manyfamiliesmaynothaveaccesstotransportation,orpublictransportationmayseemtoocumbersomewithachildin-tow,especiallywhenconsideredinconjunctionwiththeoverridingstressorsmentionedabove.

Language barriers:thesocietaldiscriminationexperiencedbypeoplewithEnglishasasecondlanguagemaymakethemmorecautioustoenterpotentiallyculturallyincongruentenvironments,suchasthoseposedbypublichealthoffices.Additionally,thedifficultyandstressofcommunicatingwithanEnglishspeakingdentalpractitionerwhomightusespecializedjargonmaybeparticularlyinhibitoryforfamilieswhohaveEnglishasasecondlanguage.

Distrust of public health professionals:manyfamiliesmayavoidpublichealthservices,regardlessofneed,duetoafearofchildapprehensionand/orbeingreportedtochildwelfareagencies.62, 63AsunderscoredbytheBCAboriginalChildareSociety:64

61Federal,ProvincialandTerritorialDentalDirectors,A Canadian oral health strategy(TheFederal,Provincial,TerritorialDentalDirectorsGroup,2005),http://www.fptdwg.ca/assets/PDF/Canadian%20Oral%20Health%20Strategy%20-%20Final.pdf.62BCAboriginalChildCareSociety,Handbook of Best Practices in Aboriginal Early Childhood Programs,2003(Vancouver,BC:BCAboriginalChildCareSociety,2003).63AlisonGerlach,Steps in the Right Direction: Connecting & Collaborating in Early Intervention Therapy with Aboriginal Families & Communities in British Columbia,1sted.(Vancouver,B.C.:BCAboriginalChildCareSociety,2007).64BCAboriginalChildCareSociety,BC Aboriginal Child Care Society Responds to Ministry of Education Draft Early Learning Framework(Vancouver,BC:BCAboriginalChildCareSociety,2007).

“There’s so many factors – life is hard for a lot of our, the families of children, you know, they might be dealing with alcoholism or drug use or physical abuse, or, and unhealthy situations. So … fluoride varnish? … teeth are really low on the radar.”

Focus-Group-Participant, FHA


“Because of the history of residential schools, the child protection system / “60”s scoop”, and other aspects of the relationship between First Nations and institutions of mainstream society, many First Nations families are wary of entrusting their young children to formal, non-familial care and education programs (p. 5).”

TheabovebarriersthatwereconfirmedbydentalstaffalsomirrorthosebarrierstoaccessinghealthandearlychilddevelopmentresourcesthatHELPidentifiedinconjunctionwithcommunityserviceproviders:Transportation,Language,SocialDistance(e.g.,lackoftrust,embarrassment),TimePoverty,andParentalConsciousness(e.g.,awarenessofthebenefitsofprograms/services).65

Ofnotewithrespecttobarrierstoaccessingpreventivedentalcare,isthatdentalstaffreportedthattheabovementionedbarrierscandisproportionatelyaffectspecificdemographicgroups:familieswithlowincome,lone-parentfamilies,familiesresidinginruralorremotelocations,recentimmigrantfamilies,familiesofAboriginaldescent,andthosefamilieswithspecialneeds.Additionally,oneshouldunderstandthatbarriersmaynotbeeasilyaddressedinisolationfromeachother,asfamiliescanexperiencemultiplebarriers.Considerationofthesebarrierscouldbeusefulinplanningfutureservicedelivery.

Considering Aboriginal CommunitiesAsstatedabove,Aboriginalidentityaccountedfor22.8%ofthevariabilityofdentaldecayinthe2009/10Kindergartensurvey,andassuch,AboriginalidentityisasignificantpredictorofdevelopingearlychildhooddentaldecayinBritishColumbia.FirstNationspeopleonreservereceiveamixofdentalhealthpreventionservicesfundedthroughregionalhealthauthoritiesandHealthCanada’sFirstNationsandInuitHealthprogram(includingtheChildren’sOralHealthInitiative).66BarrierspreventingAboriginalfamiliesfromaccessingoralhealthcarewhichwerediscussedinthefocusgroupincluded:lackoftransportation,missedimmunizationappointmentsduetotoomanyoverridingstressors,asenseofmistrusttowardspublichealthservices,bandnursesnotbeingawareofcariesriskscreening,andAboriginalparentsnotfeelingcomfortablewithenteringhealthunits.67

UnderstandingandappreciatingthesebarrierstoaccesscanhelppublichealthdentalstafftobetterreachAboriginalfamiliesandcommunitiesonthetopicoforal-healthcare.UNICEFCanadastatedthat“nowhereisthehealthdisparitybetweenAboriginalandnon-Aboriginalchildrenmoreevidentthanindentalhealth.”68InoneAboriginalcommunitywithinOntario,forexample,74%ofthechildrenbetween3and5yearsofagehadpreviousexperiencewithcariouslesions.FocusgroupdiscussionspertainingtomethodsfordismantlingbarrierstocarethatmanyAboriginalfamiliesexperiencecenteredon:culturalsafetytrainingfordentalstaff,communityoutreachinitiatives,communitypartnerships,andtryingtomitigatesomeoftheextraneousstressorssuchastransportation.

65J.Schroederetal.,Creating Communities for Young Children: A Toolkit for Change(Vancouver,BC:HumanEarlyLearningPartnership,2009).66BCMinistryofHealthServices,Dental Survey of Aboriginal Kindergarten-Aged Children 2009-2010: A Provincial and First Nations School Analysis.67UNICEFCanada,“Aboriginalchildren’shealth:Leavingnochildbehind”(CanadianUNICEFCommittee,2009),15.68UNICEFCanada,“Aboriginalchildren’shealth:Leavingnochildbehind.”


SummaryOverall,thefindingsrelatedtocariesriskassessmentandbarrierstoaccessingpublichealthserviceshighlighttwoareasforfutureconsideration.First,thevarietyofhealthauthorityriskassessmenttoolsandguidelinesthatarecurrentlybeingusedacrosstheprovincecouldbestandardizedintoonecoherentandcomprehensivetoolkitforusebyallhealthauthorities.Thisstandardizedtoolkitcouldincludeariskassessmenttool,guidelinesandfollow-uptechniquesthataregroundedinthekeythemesthatemergedfromtheenvironmentalscan.Second,thefindingsilluminatedthespecifictypesofbarriersthatpreventfamiliesfromaccessingpublichealthservices,andthatdisproportionallyaffectpopulationsofconcern.


HEALTH PROMOTION AND PREVENTIVE STRATEGIES

3. Are health promotion interventions effective in supporting family dental health practices toward reducing early childhood caries?

Publichealthdentalfocusgroupparticipantsindicatedthatforparticipatingfamilies,thedentalhealthriskassessmentwaseffectiveinsupportinghealthyparentpracticeswhenusedinconjunctionwithpreventivecounseling,education,oradditionalsupport.Strategiesforsupportinghealthyparentpracticeshighlightedbydentalstaffincludedtailoredgrouphealtheducationsessionstopopulationsofconcern,buildingrapportandtrust,motivationalinterviewing,roleplaying,andtoothfairycostumes.DentalstaffinVCHAandVIHAattributedimprovementsinparentawarenessandchildren’soralhealthtodentalstaffcommunityhealthpromotioneffortsprioritizingpreschoolprogramsasjuice-freeenvironments.Dentalstaffacrossallhealthauthoritiesreporteddifficultyreachingvulnerablepopulationsasabarriertoprogramcoverageandeffectivenessingeneral.

Asystematicreviewoftheresearchconcludedthatstrategiestargetinghigh-riskgroupswithinawholepopulationmayhelpreduceinequalitiesinoralhealth.69Mailingfluoridetoothpastetoaspecific“at-risk”populationofchildrenfrom12monthsonwardalsowasassociatedwithreducedcariesprevalenceinkindergartenchildren.70In2004,aGlasgowcommunitydevelopmentprograminalowincomeareaaimedtodeliverconsistentmessages,improvediet,provideaccesstofluoridetoothpaste,andsupportpreschooltoothbrushingprograms.71Overfouryears,thismulti-strategyprogramwasassociatedwithsignificantimprovementsinpreschooldentalhealth.Similartoourfindings,arecentUSfocusgroupstudyamongcaregiverswithlowincomesconcludedthatcommunity-basedoralhealthinitiativesshouldemphasizedevelopingtrustofcaregiverswithserviceproviders.72

69AndrewJ.Sprod,RobertAnderson,andElizabethT.Treasure,Effective oral health promotion: literature review,Technicalreports20(Cardiff:HealthPromotionWales,1996).70G.M.Daviesetal.,“Arandomisedcontrolledtrialoftheeffectivenessofprovidingfreefluoridetoothpastefromtheageof12monthsonreducingcariesin5-6yearoldchildren,”Community Dent.Health19,no.3(2002):131-136.71YBlairetal.,“Glasgownursery-basedcariesexperience,beforeandafteracommunitydevelopment-basedoralhealthprogramme’simplementation,”Community Dental Health21,no.4(2004):291-298.72S.E.Kellyetal.,“BarrierstoCare-SeekingforChildren’sOralHealthAmongLow-IncomeCaregivers,”Am J Public Health95,no.8(2005):1345-1351.

Healthyfamilydentalpracticesmaybemosteffectivelysupportedbytailoringservicesforpopulationsofconcernandbuildingtrustwithfamiliesthroughclient-centeredapproaches(e.g.,MotivationalInterviewing).

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BUILDING PARTNERSHIPS

4. What strategies are used in the health authorities to prevent early childhood dental disease? What is the most effective combination of strategies being provided in the health authorities to prevent early childhood dental disease?

Inadditiontothedentalhealthriskassessmentandfluoridevarnishprograms,dentalstaffdescribedseveralpreventivestrategiesusedinhealthauthorities,asoutlinedbelow.

Community outreach:Communityoutreachwasfrequentlymentionedasthemosteffectivestrategyforreachinghard-to-reachpopulationsthatweretypicallymissedbypublichealthdentalteams.ThisfindingisechoedbytheUSSurgeonGeneralrecommendationthat“partnershipsbeusedtoimprovedoralhealth.”73Bybuildingpartnershipswithcommunityorganizations,publichealthdentalprogramscanefficientlyexpandtheirprogramcoveragetoincludethefamiliesthatthecommunitypartnersalreadyworkwith.Typesofcommunitypartnerswhichwerehighlightedbydentalstaffincluded:drop-inprograms,healthfairs,communityevents,supportgroups,infantprograms,parentinggroups,earlychildhooddevelopmentnetworks,preschools,schooldistricts,andindividualcommunitychampions.SpecificorganizationsthatwerementionedinreferencetocommunityoutreachincludedStrongStart,HealthiestBabiesPossible,andAboriginalFriendshipCentres.Similarly,theSurgeonGenerallistedcommunityprogramssuchasHeadStartandsupplementalfoodprogramsaspotentialpartners.Additionally,Andersen’srevisedaccesstocaremodelincludescommunityprogramsasenablingfactorsthatmaybeprecursorsforutilizationofavailableoralhealthservices.74Communityprogramscanimprovethelinksbetweenfamiliesandoralhealthcarethroughreferralsandnetworking,75withcommunityprogramstaffbeingwell-positionedtoidentifychildrenvulnerabletocariesatanearlyage.76

Building rapport and trust with families:Afocusonbuildingarapportwithfamilieswasrepeatedlyhighlightedasbeinganeffectivestrategyforreducingearlychildhoodcaries.Buildingtrust,rapport,andrespectwithclientsoftenencouragestheclients,induetime,tofollowhealthpractitioner’ssuggestionsforhealth-promotingpractices.77Accordingtoparticipants,buildingrapportmay

73DepartmentofHealthandHumanServices,Oral Health in America: A Report of the Surgeon General(Rockville,MD:DepartmentofHealthandHumanServices,NationalInstituteofDentalandCraniofacialResearch,NationalInstitutesofHealth,2000).74RonaldAndersen,Changing the US health care system: Key issues in health services, policy, and management,2nded.(SanFranciscoCalif.:Jossey-Bass,2001).75C.M.Jonesetal.,“Creatingpartnershipsforimprovingoralhealthoflow-incomechildren,”Journal of Public Health Dentistry60,no.3(2000):193-196.76JessicaY.Lee,“Chapter10:Communityprogramsandoralhealth,”inEarly Childhood Oral Health,ed.JoelH.BergandRebeccaL.Slayton(Ames,Iowa:Wiley-Blackwell,2009),223-236.77KarenSaucierLundyandSharynJanes,Community health nursing: Caring for the public’s health(Sudbury,MA:Jones&Bartlett,2009).

Preventivestrategiescouldincludecommunityoutreachandpartnership-building,integrationwithexistingpublichealthprograms,andsupportingfamiliesinaccessingdentalcare.

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allowcaregiverstofeelmoreateasetodisclosemoreaccurateinformation,fromwhichdentalstaffcanprovidethemostappropriatefollow-up.Additionally,buildingrapportwithfamiliescanhelptobuildtrustbetweencaregiversanddentalstaff,alackofwhichisstatedtoinhibitsomepopulationsfrommorefrequentlyaccessingpublichealthservices.Aboriginalpopulationsforexample,areperhapstheonepopulationwiththemostentrencheddistrusttowardspublichealthinitiativesduetothedecadesofunqualifiedremovalofAboriginalchildrenfromAboriginalfamilies.ApplyingtheirframeworkfororalhealthdisparitiesinacasestudyofAlaska,Patrickandcolleaguesmaintainthat“rapport,trust,andtribalcooperation/collaborationandendorsementarenecessarytoaddresscommunityoralhealthissues.”78AfocusonearningthetrustofAboriginalfamiliesandcommunities,maythereforebe,themosteffectivestrategyforaddressingdentalhealthissuesinAboriginalcommunities.PleasenotethatanimportantprecursortoearningthetrustofAboriginalfamiliesmaybeimplementingculturalsafetytrainingforstaff.Culturalsafetydiffersfromculturalsensitivity,inthatitshiftsthefocusfromindividualinteractionstosocietal/structurallevelinequitiesforminoritygroups.79, 80Ithelpsparticipantstothinkcriticallyabouttheirownsocialpositionbybeing“mindfuloftheirownsociocultural,economic,andhistoricallocation.”81Societallevelpowerimbalancesbecomesalientinculturalsafetytraining,leadingtomoresensitiveandeffectiveservices.82AnAboriginalculturalsafetytrainingworkshopdeliveredtoGeneralPractitionersinAustralia,foundthatthemosteffectiveculturalsafetytrainingprocedureswerethosethatweredevelopedinpartnershipwithlocalAboriginalcommunities;theseworkshopswerereportedtohavealongtermeffectonchangestoclinicalpracticesandtheGP’sability/comforttoliaisewithlocalAboriginalcommunities.83

Building partnerships with other health practitioners:Buildingpartnershipswithhealthpractitioners,includingotherpublichealthpractitionersandprimarycareproviders,similartothecommunitypartnershipsdiscussedabove,canexpandprogramcoveragebyreachingthosefamiliesthatotherhealthpractitionersarereaching.Withinpublichealth,partnershipswithPublicHealthNurses,healthunitaides,andadministrativestaff,allofwhomcanplayakeyroleinmakingreferrals,couldbequitevaluable.Bothimprovedhealthoutcomesandsignificantbehaviorchangeshavebeenempiricallylinkedtopartnershipbuildinginpublichealth.84Coordinatedcareinvolvingprimarycareproviderscanfacilitatereferrals,preventionoforaldiseaseandhealthpromotion,andearlyidentificationofdentaldisease.85

78D.L.Patricketal.,“ReducingOralHealthDisparities:AFocusonSocialandCulturalDeterminants,”BMC Oral Health6,no.1(2006):S4-S4.79N.R.Polaschek,“Culturalsafety:anewconceptinnursingpeopleofdifferentethnicities,”Journal of Advanced Nursing27,no.3(1998):452-457.80NationalAboriginalHealthOrganization,Cultural Competency and Safety: A Guide for Health Care Administrators, Providers and Educators(NationalAboriginalHealthOrganization,2008).81J.Andersonetal.,“‘Rewriting’culturalsafetywithinthepostcolonialandpostnationalfeministproject:Towardnewepistemologiesofhealing,”Advances in Nursing Science26,no.3(2003):196.82F.Hart-Wasekeesikaw,D.Gregory,andM.Hart,Cultural Competence and Cultural Safety in First Nations, Inuit and Métis Nursing Education: An Integrated Review of the Literature(Ottawa,ON:AboriginalNursesAssociationofCanada,2009).83AboriginalHealthCouncilofWesternAustralia,Delivery of a Cultural Safety Training Pilot Program: Final Report to The Royal Australian College of General Practitioners (Perth, Western Australia: Aboriginal Health Council of Western Australia, 2005).84PartnershipforthePublic’sHealth(ProgramOffice),Strategies for Building Community-Public Health Partnerships(California,US,2007).85WendyMouradianandRussellMaier,“Thetotalhealthteam:Workingtogethertoimprovechildren’shealth,”inEarly

“Relationship building and building trust – I think that’s key for getting that prevention and health promotion messaging out.”

Focus Group Participant, VCHA


Partnershipbuilding,asastrategyforprovidingoralhealthcareiscommensuratewithanupstreamapproachtohealthcarewhichconsiderstheunderlyingsocialdeterminantsoforalhealth.86, 87Collaborationandcoordinationshouldalsobeconsideredwithfederalprogramsthatprovideservicesonreserve,suchastheChildren’sOralHealthInitiative(COHI),HealthCanada’sMaternalandChildHealthprogram,andFirstNationsandInuitHealth.

Advocacy efforts:Manydentalstaffstrivedtoactasadvocatesinfacilitatingaccesstooralhealthcareforfamiliesinneed.Advocacyeffortsincluded:a)workingwithfamiliesandcommunitychampionstofacilitateaccesstoreduced-costservicesanddentalaccessfunds,b)phoningdentalreceptioniststoadvocateforaclientafteramissedappointment,andc)maintaininglistsofdentistsandinformationregardingtheaccessibilityofvariousdentalservices.

TheseeffortssupportCanadianOralHealthStrategy88recommendationsforhealthregionsto:

• Maintaininformationonoralhealthprofessionalswhoprovideservicesoutsidethetraditionalpracticesettings,andtheirexperiencesandchallenges;

• Continueeffortstodevelopprogramsandservicesthatrecognizethedifferenthealthcareneedsofthesectorsthathavereducedaccesstocare;

• Arrangeclinicsfororalcareusingacollaborativeteamapproach.

Somedentalstaffalsofacilitateroleplayingactivitiesinparentgroups,whichfocusonhowtocommunicatewithdentalreceptionistswhentheyarehavingdifficultyobtaininganappointment(e.g.,afterapreviousmissedappointment).Dentalstaffhavedescribedroleplayingactivitiesasbeingabletohelpparentstolearnhowtoself-advocatefortheirchild’soralhealth,tolearnstrategiesforre-entryintothedentistclinic,andtounderstandhowmissingappointmentsimpactsthedentaloffice.Additionally,dentalstaffhaveworkedtofacilitateaccesstotheChildren’sOralHealthInitiative(COHI)byencouragingandsupportingAboriginalcommunityapplicationstothisfederalprogramfundedbyFirstNationsandInuitHealth.

Inadvocatingforindividualchildren’accesstodentalcare,dentalstaffmembersarerespondingtoadocumentedsocialgradientinaccesstodentalcare89, 90, 91wherebyhealthinequalitiesandtypesandnumbersofbarrierstoaccessingservicesarestronglytiedtolevelsofsocioeconomicadvantage.AdditionalrecommendationsforhealthregionstoimproveaccesstocarefromtheCanadianOralHealthStrategyinclude:

• Providecontinuingeducationonoralhealthserviceprovisionforspecialpopulationsthatexhibitlowdentalserviceutilizationrates.

• Increasethedeliveryoforalhealthcareoutofcommunityhealthcenters.

Childhood Oral Health(Iowa:JohnWileyandSons,2009),237-261.86R.G.Watt,“Fromvictimblamingtoupstreamaction:tacklingthesocialdeterminantsoforalhealthinequalities,”Community Dent.Oral Epidemiol.35,no.1(2007):1-11.87S.Gehlertetal.,“Targetinghealthdisparities:Amodellinkingupstreamdeterminantstodownstreaminterventions,”Health Affairs27,no.2(2008):339-349.88Federal,ProvincialandTerritorialDentalDirectors,ACanadianoralhealthstrategy.89A.N.Donaldsonetal.,“Theeffectsofsocialclassanddentalattendanceonoralhealth,”Journal of Dental Research87,no.1(2008):60-64. 90X.-L.Gaoetal.,“Behavioralpathwaysexplainingoralhealthdisparityinchildren,”Journal of Dental Research89,no.9(2010):985-990.91A.E.Sanders,A.J.Spencer,andG.D.Slade,“Evaluatingtheroleofdentalbehaviourinoralhealthinequalities,”Community Dentistry and Oral Epidemiology34,no.1(2006):71-79.


• Increaseawarenessandmobilizethepublictoadvocateforuniversalaccesstodentalcare,whichiswelldesignedandadequatelyfunded.

Outreach to prenatal and postnatal groups:Giventhatcariogenicbacteriacanbetransmittedfromcaregivertochildandmaternaloralhealthisastrongindicatorofchildren’soralhealth,evenaftercontrollingforpovertystatus,92, 93preventioneffortsattheprenatalstagecanreducetheriskofECC.94, 95, 96, 97, 98Prenatalgroupswerediscussedinthefocusgroupsasanidealplacetoconductpreventiveeducationbeforedailyparentingbecomesanoverridingpriority.

Promoting healthy preschool environments:Somedentalstaffhaveworkedwiththeirlocalpreschoolstopromotejuice-freeenvironments,whichnotonlyreducesthechildren’ssugarintake,butalsohelpsparentstobuildanawarenessofgoodoralhealthpractices.Dentalstaffreportedobservablereductionsintheamountofearlychildhoodcariesfoundinthepreschoolswithwhichtheyhavepartneredtocreatejuice-freeenvironments.Onestudyfoundthatpreschoolpoliciesonavailabilityoffoodsandsnackscanleadtoreducedsugarintakeinthepreschoolandathome.99

What are the most effective combinations of strategies being used to reduce early childhood caries?Programeffectivenesswasnotquantifiableduetoalackofconsistentelectronichealthrecordsdatalinkingdeliveryofpreventiveservicestochildhealthoutcomes.Inthefocusgroups,publichealthdentalstaffemphasizedtheintegrationofpreventivedentalserviceswithexistingpublichealthandcommunitypartnerinitiativesasawaytoimprovedentalhealthoutcomes.Therewerefrequentcallsforspecificpreventivestrategiesincluding:integrationwithexistingcommunityinitiatives,communitydevelopment,partnership-building,promotionofhealthypreschoolenvironments,andinvolvementofinterdisciplinarypublichealthteams.

Whenaskedtoidentifypriorityactivitiesforallocationofstafftime,IHAdentalstaffrankedcommunity-levelservicesaspriorityactivitiestheycouldspendmoretimeontohaveahigherimpactonoralhealthstatus.Inparticular:• Developingadentalprogrambasedonidentifieddentalneeds,inconjunctionwiththehealthunitteamandcommunity.

• Providingdeliveryofdentalhealthlessons/demonstrationsforindividuals,parents,children(e.g.,StrongStartsites),andgroupsincommunitysettings.

• Coordinatinginter-agencyprogramsinthecommunityrelatedtothedentalprogram.

92J.Lapirattanakuletal.,“Demonstrationofmother-to-childtransmissionofstreptococcusmutansusingmultilocussequencetyping,”Caries Research42,no.6(2008):466-474.93B.A.Dyeetal.,“Assessingtherelationshipbetweenchildren’soralhealthstatusandthatoftheirmothers,”Journal of the American Dental Association(1939)142,no.2(2011):173-183.94S.S.Gomez,A.A.Weber,andC.G.Emilson,“Aprospectivestudyofacariespreventionprograminpregnantwomenandtheirchildrenfiveandsixyearsofage,”ASDC Journal of Dentistry for Children68,no.3(2001):191-195,152. 95S.S.Gomezetal.,“Prolongedeffectofamother–childcariespreventiveprogramondentalcariesinthepermanent1stmolarsin9to10-year-oldchildren,”Acta Odontologica Scandinavica65,no.5(2007):271-274. 96P.Isokangasetal.,“Occurrenceofdentaldecayinchildrenaftermaternalconsumptionofxylitolchewinggum,afollow-upfrom0to5yearsofage,”Journal of Dental Research79,no.11(2000):1885-1889. 97K.Meyer,W.Geurtsen,andH.Günay,“Anearlyoralhealthcareprogramstartingduringpregnancy,”Clinical Oral Investigations14,no.3(2009):257-264.98K.PlutzerandA.J.Spencer,“Efficacyofanoralhealthpromotioninterventioninthepreventionofearlychildhoodcaries,”Community Dentistry and Oral Epidemiology36,no.4(2008):335-346. 99C.S.RodriguesandA.Sheiham,“Therelationshipsbetweendietaryguidelines,sugarintakeandcariesinprimaryteethinlowincomeBrazilian3-year-olds:alongitudinalstudy,”International Journal of Paediatric Dentistry10,no.1(2000):47-55.


ResearchintheUnitedStateshasuncoveredsimilarfindingstotheextentthattheU.S.SurgeonGeneralhasendorsedpartnershipsasawaytoimprovedentaloutcomes.100Childreninvolvedwithcommunityinitiatives,programs,ororganizationshaveanincreasedlikelihoodofdentistvisitation,as“communityprogramscanserveasavehicletoincreaseaccesstotheoralhealthcaresystem.”101

Areviewofpublichealtheducationinterventionsconcludedthatforschool-agedchildren,healtheducationinterventionsaloneareinsufficienttochangeparenthealthpracticesbutcanbeeffectivewhencombinedwithenvironmentalorlegislativechanges,suchaschangestoschoolmeals.102One-to-onedentalhealtheducationhasnotbeenfoundtobeconsistentlyeffectiveinchangingbehaviour.103Similarly,one-to-onedietaryadvicehasnotbeenconclusivelyshowntopreventcaries.Astudyoflow-incomeBrazilianchildrenfoundthatpreschoolpoliciesonavailabilityoffoodsandsnackscanleadtoreducedsugarintakeinthepreschoolandathome.104Thisisconsistentwiththefocusgroupfindingsonpromotinghealthypreschoolenvironments.

Aschool-basededucationprogramdemonstratedasustainedimprovementinplaquescoresforchildreninmoreadvantagedareas,whereaschildrenfromlessadvantagedareasshowednobenefitfromtheprogram.105Thissuggeststhatinsomecasesuniversalprogramsmayservetoincreasesocialinequitiesinoralhealth,possiblyowingtofamiliesfrommoreadvantagedareasfacingfewerbarrierstoadoptingoralhealthpractices.Whileatargetedapproachwithinthemostsocioeconomicallydisadvantagedareasmayaddresstheurgentunmetdentaltreatmentneedsofthemostseverelyaffectedchildren(e.g.,Codes3.3,3.4,and04),thisdoesnotaddressoralhealthinmiddle-incomeareas,inwhichalargeproportionofchildrenhavingexperiencewithtreateddecayand/ornewdecayreside(e.g.,Codes02,3.1).TheMarmotReviewadvocatesforwhattheycallproportionateuniversalism,statingthat“toreducethesteepnessofthesocialgradientinhealth,actionsmustbeuniversal,butwithascaleandintensitythatisproportionatetothelevelofdisadvantage.”106

SummaryOverallthefindingspertinenttoevaluationquestion#4suggestthatbuildingpartnershipsandrelationshipswithcommunityorganizations,publichealthpractitioners,andfamilies,canbehighlyinfluentialwithrespecttoincreasingprogramreach,effectiveness,andefficiency.Itisnotjustthatmoreservicesareneeded,butthatservicesneedtobeofferedthroughcertaintypesofpartnerships,suchasthosewithpreschools,prenatalgroups,publichealthnurses,andearlychildhoodservices.ThisfindingiscommensuratewithrecommendationsfromtheCanadianOralHealthStrategyreportwhichstatesthataccessneedstobeconsideredalonggeographic,financial,social,cultural,andlegislativeterms.107

100Lee,“Chapter10:Communityprogramsandoralhealth.” 101Ibid. 102ScottishExecutive,Nursing for health: a review of the contribution of nurses, midwives and health visitors to improving the public’s health in Scotland(Edinburgh:TheStationeryOffice,2001). 103E.KayandD.Locker,“Asystematicreviewoftheeffectivenessofhealthpromotionaimedatimprovingoralhealth,”CommunityDentalHealth15,no.3(1998):132-144;E.KayandD.Locker,“Isdentalhealtheducationeffective?Asystematicreviewofcurrentevidence,”Community Dentistry and Oral Epidemiology24,no.4(1996):231-235.104RodriguesandSheiham,“Therelationshipsbetweendietaryguidelines,sugarintakeandcariesinprimaryteethinlowincomeBrazilian3-year-olds.” 105Sprod,Anderson,andTreasure,Effective oral health promotion. 106StrategicReviewofHealthInequalitiesinEnglandpost-2010,“Fairsociety,healthylives:TheMarmotreview”(StrategicReviewofHealthInequalitiesinEnglandpost-2010,2010).107Grindefjordetal.,“Predictionofdentalcariesdevelopmentin1-year-oldchildren.”


GENERAL THEMES

Threebroadthemescharacterizethefindings:surveillanceissues,standardizationofassessmenttools,andpartnershipbuilding.

Surveillance: Is the oral health of young children improving?

Change over time and variability in dental decay rates across BC neighbourhoodsTheresultsoftheKindergartenDentalSurveyindicatedthat,ataprovinciallevel,thereweremodestimprovementsindentalstatusatkindergartenacrossthetwodentalsurveyyears.Thesechangeswerenotuniform,however,astherewerechangesinvisibledentaldecayrates(increasesanddecreases)thatweremoreextensiveinsomegeographiclocationsthanothers.

Similarly,visibledentaldecayratesineachsurveyyearvariedacrossneighbourhoodswithsomeinstancesofadjacentneighbourhoodshavingdisparatevisibledentaldecayoutcomes(e.g.,TsawwassenNorth,DawsonCreekCentre).ThesedifferencesindentalhealthoutcomesacrossgeographicareasinBCindicateoralhealthdisparitiesthatparallelthosefoundwithotherhealthoutcomes,suchaslifeexpectancyandprematuremortalityrates.

Social influences on dental health outcomesThefindingsfromthisprojectsuggestthatvariationinvisibledentaldecayratesacrossregionswasnotrandom.Theratesofvisibledecayinthemajorityofneighbourhoodssurveyedindicatedthatsocialfactors,includingthesocioeconomicconditionsanddemographiccharacteristicsthatcharacterizewhereachildlives,werepredictiveofdentalhealthoutcomesatkindergarten.Childrenresidinginmoresocioeconomicallyadvantagedareastendedtohavelowerratesofvisibledentaldecaythanthosechildrenresidinginsocioeconomicallydisadvantagedareas.Thisfindingisconsistentwiththelargebodyofevidenceindicatingtheinfluencethatindividual-andneighbourhood-levelsocioeconomiccircumstanceshaveondisparatehealthoutcomesacrossgeographicareas.108, 109, 110, 111, 112,113, 114, 115, 116

Analysisofthekindergartendentalsurveydatainboth2006/07and2009/10indicatedthattherewasvisibledentaldecayforapproximatelyhalfofthe

108W.Sabbahetal.,“Theroleofhealth-relatedbehaviorsinthesocioeconomicdisparitiesinoralhealth,”Social Science & Medicine68,no.2(2009):298-303. 109J.M.Armfield,“Socioeconomicinequalitiesinchildoralhealth:Acomparisonofdiscreteandcompositearea-basedmeasures,”Journal of Public Health Dentistry67,no.2(2007):119-125. 110J.L.F.Antunesetal.,“Spatialanalysistoidentifydifferentialsindentalneedsbyarea-basedmeasures,”Community Dentistry and Oral Epidemiology30,no.2(2002):133-142. 111L.G.Doetal.,“TrendofIncome-relatedInequalityofChildOralHealthinAustralia,”Journal of Dental Research 89,no.9(2010):959-964. 112K.A.Levinetal.,“Inequalitiesindentalcariesof5-year-oldchildreninScotland,1993–2003,”TheEuropeanJournalofPublicHealth19,no.3(2009):337-342. 113K.E.PickettandM.Pearl,“Multilevelanalysesofneighbourhoodsocioeconomiccontextandhealthoutcomes:acriticalreview,”Journal of Epidemiology and Community Health55,no.2(2001):111-122. 114M.Tellezetal.,“Assessmentoftherelationshipbetweenneighborhoodcharacteristicsanddentalcariesseverityamonglow-incomeAfrican-Americans:Amultilevelapproach,”Journal of public health dentistry66,no.1(2006):30–36.115G.Turrelletal.,“Theindependentcontributionofneighborhooddisadvantageandindividual-levelsocioeconomicpositiontoself-reportedoralhealth:amultilevelanalysis,”Community Dentistry and Oral Epidemiology35,no.3(2007):195-206. 116S.Willemsetal.,“Theindependentimpactofhousehold-andneighborhood-basedsocialdeterminantsonearlychildhoodcaries:across-sectionalstudyofinner-citychildren,”Family & Community Health28,no.2(2005):168.


childreninthemostsocioeconomicallydisadvantagedneighbourhoodsinBC.Ratesofvisibledentaldecaydecreasedor,inotherwords,improved,withincreasingsocioeconomicstatusoftheneighbourhood.In2009/10,themostsocioeconomicallydisadvantagedneighbourhoodshaveareportedvisibledentaldecayrateof48%,whereasavisibledentaldecayrateof30%,onaverage,wasreportedinareaswiththehighestsocioeconomicadvantage.Althoughtheprecisemechanismforthis‘socialgradient’indentalhealthoutcomeshasnotbeenestablished,itisclearthatdifferencesindentalhealthoutcomesexist.

Theanalysisofthekindergartendentalsurveydataindicatedthatin2006/07and2009/10,theaveragerateofvisibledentaldecaywashighestinthemostsocioeconomicallydisadvantagedneighbourhoods;whereasinthemoderatetomoderatelyhighsocioeconomicstatusneighbourhoods,approximately1in3childrenexperiencedvisibledentaldecay.Thatis,thedataindicatedthat,onaverage,higherratesofvisibledentaldecayarenotoccurringexclusivelyinthemostsocioeconomicallydisadvantagedneighbourhoods;theyaredistributedacrossvaryinglevelsofsocioeconomicstatus.

Thereisagrowingconsensusthatpublichealthinterventionsneedtocombinebothpopulation-basedandhigh-riskapproaches.117, 118, 119TheMarmotReviewrecommendsapolicyofproportionateuniversalisminwhich“actionsmustbeuniversal,butwithascaleandintensitythatisproportionatetothelevelsofdisadvantage.”120Itispossible,forexample,thatamulti-prongedcoordinatedapproachthatinvolvesacombinationofindividual-andcommunity-levelinterventionsmaybewellsuitedforthemostsocioeconomicallydisadvantagedareas(withhighratesofdentaldecay),whereitisexpectedthatfamiliesencountermultiple,pervasivebarrierstoaccessingservices.However,interventionsthatsolelytarget‘atrisk’individualsorthemostdisadvantagedareasarenotsufficienttoaddressthesocialgradientindentalhealth,norwouldtheyaddressthemajorityofnewlesions.121, 122, 123

Itisimportanttonotethatthesocioeconomicdataavailableforanalysesofthekindergartendentalsurveydatareflectthesocioeconomicstatusoftheneighbourhood,onaverage,andwouldnotnecessarilyreflectthesocioeconomicbackgroundofeachindividualinthatneighbourhood.Recentstudiesindicatethatbothindividual-andneighbourhood-levelsocioeconomicfactorsmayindependentlyimpactindividualdentalhealth.124, 125, 126

117P.BatchelorandA.Sheiham,“Thelimitationsofa‘high-risk’approachforthepreventionofdentalcaries,”Community Dentistry and Oral Epidemiology30,no.4(2002):302-312.118StrategicReviewofHealthInequalitiesinEnglandpost-2010,“Fairsociety,healthylives:TheMarmotreview.” 119Watt,“Fromvictimblamingtoupstreamaction:tacklingthesocialdeterminantsoforalhealthinequalities.” 120StrategicReviewofHealthInequalitiesinEnglandpost-2010,“Fairsociety,healthylives:TheMarmotreview.”121BatchelorandSheiham,“Thelimitationsofa‘high-risk’approachforthepreventionofdentalcaries.” 122StrategicReviewofHealthInequalitiesinEnglandpost-2010,“Fairsociety,healthylives:TheMarmotreview.”123Watt,“Fromvictimblamingtoupstreamaction:tacklingthesocialdeterminantsoforalhealthinequalities.”124J.Aidaetal.,“Contributionsofsocialcontexttoinequalityindentalcaries:amultilevelanalysisofJapanese3-year-oldchildren,”Community Dentistry and Oral Epidemiology36,no.2(2008):149-156.125Turrelletal.,“Theindependentcontributionofneighborhooddisadvantageandindividual-levelsocioeconomicpositiontoself-reportedoralhealth.”126Willemsetal.,“Theindependentimpactofhousehold-andneighborhood-basedsocialdeterminantsonearlychildhoodcaries.”


Drawing from population-level datasetsPopulation-baseddatacollectionthroughtheKindergartenDentalSurveyallowedforsimilaritiesanddifferencesindentalhealthoutcomesandratesofchangeovertimebyneighbourhoodtobeexamined.SurveillancethatinvolvedconsistentmeasurementofvisibledentaldecayacrossgeographiesandovertimewascriticalindevelopingabetterunderstandingoforalhealthtrendswithinBC.

Risk Assessment: Are the current dental health risk assessment/screen guidelines implemented as intended? Atthetimeofpublication,adiversityofriskassessmenttools,guidelinesandfollow-uptechniqueswerebeingusedacrosstheprovince.Creatingastandardizedtoolkitusingkeymessagingfoundintheliteratureandcurrentassessmenttoolscouldensureconsistentandcomprehensivemessaging.Standardizationoftoolsandconsistencyindatawouldallowhealthauthoritiestosharedatawithoneanotherandmakecomparisonsacrossavarietyofsettingstoinvestigatetheeffectivenessofintervention/preventionstrategies.Arigidstandardizationisnotrecommended,butinsteadtherecouldbestandardizedcomponentsoftheriskassessmenttoolsanddata,preferablythecomponentswhichwouldbeidentifiedascorefunctionsoftheriskassessments.DoingsowillallowhealthauthoritiesandHSDAsto:a)communicatewitheachotherandcomparedataonthesameelementswithoutneedfortranslation,andb)tailortheirservicestomeettheircommunities’uniqueneeds,ensuringthattheirprogramisthemostappropriatefitfortheculturalorsocialenvironment.

StandardizationalsoallowstheMinistryofHealth(MoH)toensurethateveryHSDAisup-to-datewithindustrystandards,asrevisionrolloutswouldbecentralizedandefficient.Assuch,thiswouldincreaseregionalhealthauthorities’andMoH’scapacityforservicedeliveryandprogramevaluation.Training,aswell,mayalsobeeasierwithstandardizedcomponents,astheMoH,partneredwithregionalhealthauthorities,maybeabletodeveloponecoretrainingmodulethatcouldbeaugmentedandtailoredforindividualhealthauthoritiesorHSDAsandtheirrespectivecommunities.127

Building partnerships: What strategies are used in the health authorities to prevent early childhood dental disease? Certaindemographicgroupsandchildrenresidingincertainareasoftheprovincehavebeenshowntobemorevulnerablefordevelopingearlychildhoodcaries.Anefficientandeffectivewaytoreachthesefamiliesistopartnerwithorganizationsthathavethosefamilieswithintheircatchment.Thevalueofcommunitypartnershipandpartnershipbuildingintersectorallyoracrossdisciplines(e.g.,publichealthnurse,familyphysician,dentalstaff)isconsistentwithcreationofacoordinatedsetofstrategiesthatcounteractsfragmentationandreflectsthenotionthatoralhealthproblemsdonotoccurinisolation.Apartnershipratherthandisease-specificapproachisindicativethatoralhealthproblemssharecommonriskfactors(relatedtodiet,hygiene,etc.)withotherchronicdiseasesthatarealsodisproportionatelyprevalentwithinmoredisadvantagedareas.

127P.Hawe,A.Shiell,andT.Riley,“Complexinterventions:how‘outofcontrol’canarandomisedcontrolledtrialbe?,”BritishMedicalJournal328,no.7455(2004):1561.


Buildingpartnershipswillallowpublichealthdentalstafftotailortheirprogramssothattheycanhavemaximumbenefitforthefamiliestheyaretryingtoreach.Itwillalsoallowdentalstafftoplanprogramsthatareresponsivetothecultureandetiquetteofthepopulationsresidingintheirrespectiveareas.Creatingsuchresponsiveprogrammingwillenablefamilies,whomayfeelalienatedordistrustfulofhealthcareproviders,tobuild/establishtrustwiththepublichealthsector.Additionally,publichealthdentalprogramscouldbecomeintegratedintothecommunitystructure.Workingwithcommunityorganizationsmayfacilitatedentalprogrammingthattakesintoconsiderationcommunityinputandpriorities,therebymakingdentalprogrammingmaximallysuitedandrelevanttocommunitymembers.

Furthermore,thegreatconsistencybetweenthereportedbarrierstoaccesstodentalprogramsandthoseassociatedwithfamiliesaccessingearlychildhoodprograms,moregenerally,suggestthatongoingdialogueandcollaborationwithstaffwithinearlychildhoodeducationprogramstodiscussfamilies’commonbarrierstoaccesscouldresultinacoordinatedsetofstrategiesthatpotentiallycouldhelpmorefamiliesreachservices.Itispossiblethatfamiliesfromallsocioeconomicbackgroundsmayencounterbarrierstoaccessingservices;forexample,timepovertymaybeabarriertoaccessingservicesrelevantforfamiliesacrosssocioeconomicbackgrounds.However,itisanticipatedthatfamiliesinthemostsocioeconomicallydisadvantagedneighbourhoodswouldlikelyexperienceahighernumberofbarriersrelativetothosewhoaremoreadvantagedandthatthenumberofbarriersencounteredwoulddecreasewithincreasingadvantageinsocioeconomicstatus.


STRENGTHS AND LIMITATIONS OF THE EVALUATION PROCESS

StrengthsTheevaluationprocessemphasizedaparticipatorymethodology,andeachmilestoneoftheprojectwasfinalizedincollaborationwithrepresentativesfromhealthauthoritiesandtheMinistryofHealth.Byconductingtheevaluationissuchamanner,HELPwasabletoensurethecontinuedrelevanceoftheevaluationoutcomeswithregardstothechangingneedsofhealthauthoritiesandMinistryofHealth.Additionally,bydrawinguponbothqualitativeandquantitativemethods,HELPwasabletoproviderobustfindings.Thefocusgroupsandinterviewswereabletointegratein-depthknowledgepossessedbypublichealthdentalstaffthat,onaverage,had15years(therangewas0to38years)ofexperienceinthefield.TheKindergartenDentalSurveyhadextensivecoverage,wasatthepopulation-level,andenabledanalysisofchangeinkindergartenvisibledentaldecayratesovertime,owingtopublichealthstaff’sconsistentcodingandrecordingpracticesinboth2006/07and2009/10.

Severalancillaryandregionalprojectswerealsodevelopedinadditiontotheprovincialevaluationprocess,strengtheningtheevaluationoutcomes:

• Regionalreportsforthefivehealthauthorities,• ProvincialCariesRiskAssessment(CRA)tooldevelopment&validationtemplate;

• Additionalmaps,• IHATimeUseQuestionnaire,and• BCDAMemberSurvey.

Regional Evaluation Frameworks and Focus Group ReportsInadditiontotheprovincialevaluationquestions,eachhealthauthoritydevelopedtwotothreeregionally-definedevaluationquestionswhichtargetedspecificissuesrelevanttotheirhealthauthority.Thesequestionswereincorporatedintothefocusgroupguidesandqualitativeanalysis,andabriefreportwasdevelopedforeachregion.Acopyofeachreportwasprovidedtotherespectivehealthauthority.Thetopic-areasofregionallydefinedquestionswerecomplimentarytotheprovinciallydefinedquestions,andcenteredonsuchissuesasprogramreach,outcometrends,comparisonsacrossHSDAs,andsuggestionsforprogramimprovement.

Provincial Caries Risk Assessment (CRA) Tool Development & Validation TemplateIn2007,theDentalEvaluationCommitteedecidedtodevelopastandardizedprovincialcariesriskassessmenttool.LeadinguptoMarch2008,HELPdevelopedapreliminarydraftofascreeningtool,called,“BabyToothCheck-up.”Thedevelopmentofthis5-itemprovincialCRAtoolwasinformedbyareviewoftheliterature,best-practicesbothwithinandoutsideBC,consultationswithpublichealthdentalstaff,andrecommendationsfromtheBCEarlyChildhoodDentalProgramEvaluationSubcommittee.Thefivequestionscovertopicssuchasaccesstooralhealthcare,theestablishmentofa“dentalhome,”familyhistoryofdentaldecay,oralhealthcarepractices,andnutrition.ACRAvalidationmeetingwasplannedtoestablishconsensusaroundtheindicatorstobeincludedinaprovincialCRAtool,aswellastheguidelinesandfollow-upproceduresforuseprovince-wide.This


validationprocesswasdiscontinuedinordertoevaluatetheexistingriskassessmentprocedures.However,thematerialsdevelopedremainavailableforfutureprogramplanning.TheCRAtooldevelopmentandvalidationmaterialsinclude:CRAToolkitDevelopmentQuestionnaire(toobtaininputoncontent,proceduresandguidelines),CRAIndicatorAppraisalQuestionnaire(toassessselecteditemsintermsoffeasibility,programvalue,evidence-base,andappropriatenessforadiversityofstaffandclients).

Additional MapsHELPsmappingteamproducedthreemapsbeyondtheoriginalevaluationplan,tobetterunderstandthecontextofearlychildhoodoralhealthinBC:

• DrivingDistancetoaDentistinBC• DistributionsofDentistsinBC• DentistLocationsMap(Interactivemapincludingdistributionofdentists,anddrivingdistancetoadentistinBC)

• InteractiveHealthAuthorityMaps,foreachofthefivehealthauthorities

IHA Time-Use Questionnaire and Literature ReviewATime-UseQuestionnairewasdeveloped,distributed,collected,andanalyzedfortheInteriorHealthAuthority,inreferencetooneoftheirregionallydefinedquestionontheweightingofone-on-oneversusgroup-levelservices.Thequestionnairewasconductedin2008/09,andwasfocusedonassessingtherelativeamountsofstaff-timedevotedtoindividual-levelversusgroup-levelservices.Thirteen(outoftheeighteen)IHAdentalstaffparticipatedinthisquestionnairebyansweringquestionsabouttheirtime-useoverthepreviousthreemonthperiod.TheresultsindicatethatIHAdentalstaffspend29%oftheirweeklyhoursonone-on-oneservicedelivery(e.g.,riskassessment),19%ongroup-levelservicedelivery(e.g.,educationsessionsincommunitysites),7%onsurveillance,24%onadministration,7%ontravel,14%onotheractivities,suchasemailcorrespondence.

BCDA Member SurveyIn2009,369generalpracticedentistsparticipatedinaBCDentalAssociationmembersurvey,128representingapproximately13%ofthe2938generalpracticedentistsinBC.129Thissurveyindicatedthat86%ofthedentistsinBCareawareoftherecommendationthatachild’sfirstdentalvisitshouldoccurnomorethansixmonthsaftertheeruptionofthechild’sfirsttooth,orapproximatelyattheageofoneyear-old.Only75%ofBCdentists,however,reportthattheyexaminechildrenundertheageof2years-old.Forthosedentistswhodonotexaminechildrenundertwo,abouthalfofthemreportedthatthisisdueto“PatientManagementDifficulties.”“PatientManagementDifficulties,”mayincludetimemanagementproblems,anddifficultiesgainingthetrustofthechildandcaregiver.Additionally,only36dentists(1%)specializeinpediatricdentistry,andlessthan5%(158)areemployedinrural-designatedpostalcodeareas.QuestionnaireitemsweredevelopedforinclusioninthissurveyinordertoaddressaVCH-definedregionalevaluationquestionregardingdentalvisitsforchildrenunder12months-old.

128CherylLandrigan,Personalcommunication,July29,2009.129BCCollegeofDentalSurgeons.


LimitationsOnelimitationisthattheecologicalanalysesconducted(i.e.,theoverlayofvisibledentaldatawithsocioeconomicdata)provideacharacterizationofsocioeconomicstatusofneighbourhoods,onaverage;however,theneighbourhood-levelsocioeconomicdatadonotreflectthesocioeconomicbackgroundsofallindividualsresidinginthatneighbourhood.Generalpatternscanbeacquiredthroughthesetypesofanalyses,butmoreprecisemeasurementofchildren’ssocioeconomicanddentalhealthtrajectoriesovertimewouldrequireperiodicandongoingcollectionandanalysisofaggregatedindividual-levelsocioeconomicinformationcombinedwithindividual-levelvisibledentaldecayresults.

Also,thereweretwoadditionaldatasourcesthatwereoriginallyintendedtobeincludedintheanalysis:1)electronicchildhealthrecordsfromiPHIS(thePublicHealthInformationSystem),and2)focusgroupswithparentsandcommunitypartners.

Electronic child health records of preventive services received ThedevelopmentoftheEvaluationFrameworkincludedconfirmationofasetofminimumiPHISdataelementstoprovideinformationonpreventiveservicesreceived(cariesriskassessmentandfluoridevarnish),identifiedrisk-levels,andKindergartenDentalSurveyoutcomes.TheelectronicdatasetfromiPHISwasnotavailableforanalysisduetounforeseendelaysinestablishinganInformationSharingAgreement.Assuch,HELPwasnotabletodefinitivelyrespondtoevaluationquestionsaboutthecoverageoreffectivenessofpreventiveservices.

Focus groups with parents/caregivers and community partners Thesecondkeydatasourcewhichwasnotfeasibletoobtainwithintheallottedtimeframewasthatoffocusgroupdatafromparentsandcommunitypartners.Thesefocusgroupswereoriginallydesignedtoaddressevaluationquestion#3,regardinghealthpromotioninterventionsforsupportinghealthyfamilydentalpractices.


RECOMMENDATIONS

Basedonthefindingsdescribedinthisreport,weputforthfourbroadrecommendationsforconsideration.Therecommendationsrelatetosurveillance,cariesriskassessment,programandserviceplanning,andpartnershipbuilding.

1. SurveillanceKindergarten dental survey and risk assessmentsDetermineongoingprogramdataneedstosupportsurveillanceandprogrammonitoringataprovincialandhealthauthoritylevel.Forexample,considerincorporatingcariesriskassessmentintoacoordinatedandintegratedmodeloflongitudinaldevelopmentalsurveillancethatincludescollectingandrecordingdataat12monthsofageandatkindergarten.

Recommendation 1a: ContinuetoimplementtheKindergartenDentalSurvey,usingconsistentcodingandrecordingpractices,everythreeyears(e.g.,2012/13,2015/16,etc.)tocontinuetomonitorthestateofearlychildoralhealthinBC.Trendsinvisibledentaldecaywouldbecomemorereadilyapparentaftermultipledatapointshavebeencollected.

Recommendation 1b:Utilizethedatafromthesurveystointensifypreventioninterventionsinthoseneighbourhoodsthatareidentifiedwithaconsistentlyhighincidenceofvisibledentaldecayandthosewithvisibledecayratesconsistentlyworsethanexpected(i.e.,persistentoff–diagonalneighbourhoods).Consistentdocumentationandrecordingofinformationabouttheinterventionsandpopulationsserved,aswellastheoutcomesoftheseinterventionswouldstrengthenthecapacity,bothprovinciallyandregionally,tounderstandthetypesoffactorsthatmayinfluencedifferentialratesofdecayacrossBCneighbourhoods.

2. Standardized tool developmentCaries Risk Assessment GuidelinesConsiderdevelopingProvincialCariesRiskAssessmentGuidelinesto:

• Standardizeassessmentandfollow-upprocesses(e.g.,riskfactorsassessed,timeframeforfollow-up,numberofcontactattempts,personalizedcontactmethods).

• Supportconsistentriskclassificationanddatacollection.• Standardizemessagingandresourcedevelopment(e.g.oralhealth-relatedhandouts)tofocusonconciseandconsistentcommunicationofkeyoralhealthmessagestocaregivers.

• Reinforceandexpandbestpractices(e.g.,communitypartnership,personalizedservices).

Note:Thetoolsdonotnecessarilyneedtobeexactlythesame,butstandardizedriskclassificationandresourcesshouldbedeveloped.HealthAuthoritiesarealsoencouragedtocontinueusing/developingadditionalandsupplementarytoolsthatuniquelyreflecttheirindividualregions.SeethefindingssectionforEvaluationQuestion2formoredetailedrecommendationsaboutstandardizedassessmentandfollow-upguidelines.


3. Program and service planning

Consider planning programs and services that are proportionate to reported rates of dental decay and level of socioeconomic disadvantage.Theresultsoftheanalysisofthe2006/07and2009/10KindergartenDentalSurveydatasetsindicatetheneedforpopulation-basedapproachesthataddresstheincidenceofvisibledentaldecayacrossBCneighbourhoodsofvaryingsocioeconomicstatus.Itisrecommendedtosupplementapopulation-basedapproachwithactionsthatdirectservicesinthoseneighbourhoodswithmoderateandmoderatelylowsocioeconomicstatus,aswellasprioritizeandintensifyinterventionsinthemostsocioeconomicallydisadvantagedareaswithconsistentlyhighratesofvisibledecay.Thelevel,individual-orcommunity-based,or‘intensity’ofservicescouldbetailoreddependingonthereportedratesofvisibledentaldecayandneighbourhoodsocioeconomicstatus.

4. Provincially coordinated strategies to support community-level partnerships

Community partnership initiatives for confirmed populations of concernConsiderdevelopingprovinciallycoordinatedstrategiestocollaboratewithnewandexistingcommunityorganizationsandearlylearningcentersto:• Increaseprogramreachtovulnerablepopulationsandfamilieswhomaynottypicallyaccesspublichealthservices,especiallyincommunitieswhereimmunizationsoccurprimarilyoutsidepublichealth.

Inpolicydocumentsandstrategicplans,considerincludingstatementstosupportongoingcommunityoutreachwithconfirmedpopulationsofconcernforwhomdentalprogramsshouldbespecificallytailored.Thiscouldincludeworkingwithcommunitypartnerstopromotehealthyearlychildhoodsettings(e.g.,providinghealthysnacks,educationonhealthyfeedingpractices).Fromthisevaluationproject,severalpopulationgroupshavebeenconfirmed:familieswithlowincome,familiesresidinginruralorremotelocations,recentimmigrantfamilies,familiesofAboriginaldescent,lone-parentfamilies,andthosewithspecialneeds.ThesegroupscoincidewiththepopulationsofconcernidentifiedintheCoreFunctionsforPublicHealthinBC(pleaseseethecompanionFocusGroupsProvincialAnalysisreportforspecificsuggestionsaboutnewcommunitypartnershipinitiatives).

Cultural safety trainingConsidermakingculturalsafetytrainingavailabletoalldentalstaff,particularlywithrespecttoworkingwithImmigrantandAboriginalcommunitiesandfamilies.Byofferingculturalsafetytraining,targetpopulationswhomayotherwiseavoidpublichealthfacilitiesduetofearormistrust,canbegintofeelsafewithinpublichealthservices.ThisrecommendationiscommensuratewiththeCanadianOralHealthStrategyrecommendationsforimprovingsocial/culturalaccesswhichstatesthatservicesshouldbeprovidedwherefamilies“canfeelateasefromacultural,socialandlinguisticpointofview.”Makingculturalsafetytrainingavailablecanhelpdentalstafftobeginearningthetrustofalienatedpopulations,thuspotentiallymakinganycommunityoutreachinitiativesmoreeffective.Culturalsafetytrainingayalsobenecessitatedatthemanagementlevelsoastounderstandanddismantlediscriminatorypolicies.


Public Health PartnershipConsiderdevelopingprovinciallycoordinatedstrategiestocollaboratewithorintegratedentalhealthintoexistingearlychildhoodpublichealthprograms.Partnershipsacrosspublichealthprogramsanddisciplinesthatsharecommonprioritiesandobjectives,suchasdentalhealthandnutrition,couldbeestablishedorfurtherdeveloped.130Also,PublicHealthNursescouldcommunicatekeydentalhealthmessagestofamiliesatearlypointsofcontact,particularlyatChildHealthClinicsfor2,4,6,12,and18monthsofage.Giventhatapproximatelytwo-thirdsofBC’schildrenunderagetwoyearsareup-to-dateintheirimmunizations,itisrecommendedthatdentalpublichealthcontinuetodevelopcoordinatedprimordialandprimarypreventionstrategiesthatcoincidewithchildren’simmunizationappointments.

Primary Care ProvidersConsiderdevelopingprovinciallycoordinatedstrategiestocollaboratewithprimarycareproviderswhodeliverimmunizationstoensuredentalhealthmessagingisdeliveredasapartofthevisit.Allmedicalprofessionalscaringforchildrenneedgeneralknowledgeabouttheriskfactorsfordentaldisease,maternaloralhealth,oralhygienepractices,andfluorides.131Coordinatedcarecanfacilitatereferrals,preventionoforaldiseaseandhealthpromotion,andearlyidentificationofdentaldisease.Inparticular,theconfirmedpopulationsofconcernbenefitfromateamapproachtohealthcare.

Federal Program Service ProvidersConsiderdevelopingprovinciallycoordinatedstrategiestocollaboratewithfederalprogramserviceproviderssuchastheChildren’sOralHealthInitiative(COHI),HealthCanada’sMaternalandChildHealthprogram,andFirstNationsandInuitHealth.Thiscouldincludetheplanningofcoordinatedservicesandconsistentpreventionmessages.

130J.Leeetal.,“EffectsofWICparticipationonchildren’suseoforalhealthservices,”American Journal of Public Health94,no.5(2004):772.131MouradianandMaier,“Thetotalhealthteam:Workingtogethertoimprovechildren’shealth.”


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APPENDIX A: Evaluation Matrix

1. Is the oral health of young children improving? a) By community b) By vulverability?

Data Sources Data Collection by Indicator/Measure

KindergartenDentalSurveyDentalDataSet

ElectronicChildHealthRecord(e.g.,iPHIS,PARIS).

Dataregardingvulnerablepopulations:EarlyDevelopmentInstrument(EDI)Census2001MinistryofEducation

HAsendscompletedschool-levelspreadsheetandindividual-level(2009-10)kindergartendentalsurveyoutcomedata.

HAentersandsendsdentalservicedatainChildElectronicHealthRecord(e.g.,iPHIS).

HELPoverlaysschool-level(2006-07)andindividual-level(2009-10)dentalsurveyoutcomeswithde-identifieddatafromothersourcesregardingvulnerablepopulations(neighbourhood-levelandindividual-level.

%ofkindergartenchildrenbydentalsurveyoutcomecode(Code01,02,03,04),byyear,bycommunity,byvulnerability(EDI,SES).Changeindentalsurveyoutcomecode(Code01,02,03,04)overtime,bycommunity,byvulnerability.

%ofchildrenbydentalhealthriskassessmentcategory(regionallyspecific)byyear,bycommunity,byvulnerability(EDI,SES).Changeindentalhealthriskcategoryovertime,bycommunity,byvulnerability.

%receivingpublichealthdentalservicebyDentalServiceType(e.g.,CRA,FV1,FV2,FV3)

2a. Are the current dental health risk assessment/screen guidelines implemented as intended?

Programrecords(e.g.,brochures,logicmodel),strategydocumentsorreports.Consultationmeetingnotes.DentalhealthriskassessmentEnvironmentalScan.

HAstaff/designates(e.g.DentalHygienists,CertifiedDentalAssistants)

HAparticipationinfocusgroup/interview/questionnaire.

DescriptionbyHAof-Thedentalhealthriskassessmenttool/questionsarebeingusedwithchildrenaged0-5.-Age(s)theseassessmentsarebeingadministered.-Thetypesofstaffadministeringthedentalhealthriskassessment.-Theguidelinesandfollow-upbeingused.-Theextentthatprogramidentifiesabroadspectrumofchildrenatriskforcaries.-Forthoseeligiblechildrenwhodentalpublichealthisnotreaching,identificationofthebarriers.Reportofkeythemesandrecommendations;Lessonslearned.

2b. To what extent does the dental health risk assessment/ screen reach young children?

ElectronicChildHealthRecord(e.g.,iPHIS,PARIS).

HAentersdentalservicedata(tobedefined)inChildElectronicHealthRecord(e.g.,iPHIS,PARIS).

%childrenscreened/assessedbyECHA/dentalhealthriskassessment.

%childrenperdentalhealthriskcategory.


3. Are health promotion interventions effective in supporting family dental health practices toward reducing early childhood caries?

HAstaff/designates:Keyregional/provincialstrategydocumentsorreports,interviewtranscript(s),questionnaire(s),orfocusgroupsummaries.

Parentsandcommunitypartners:Interviewtranscript(s),questionnaire(s),orfocusgroupsummaries.

HAstaff/designatesparticipationthroughinterview,questionnaire,orfocusgroupandprovisionofrelevant,keydocumentstotheHELPevaluationteam(tbd).

HELPParent Question-naire,Interview,orFocusGroup(tbd)

HELPCommunity Partner Questionnaire,Interview,orFocusGroup(tbd).

HAsmayassistinre-cruitment(e.g.,distributequestionnairestoparents,makebrochuresavailable).

Amongparents:-Proportionofparentsindicatingamoderateorhighknowledgeabout“healthpromoting”dentalpractices.

-Proportionofparentsindicatingchangesinattitudes,behaviour/skills,andknowledgeasaresultofhealthpromotion.

-%ofparentsreportingeachbarrier/facilitatortohealthpromotionandbehaviourchange.

-Evidencethatfamilieshavebetteraccesstopreventiveeducation.

Amongcommunitypartners:-Evidenceofalliedhealthprofessionalswhoreceiveddentalhealthpromotioneducation(e.g.mixortypesofprofessionals).-Communitymembersworkingwithfamiliesareawareoforalissuesincludingparentingskillsforprevention,andaccesstotreatment.

Strengthenedcommunitypartnerships:-Increaseddentalhealthpromotionthroughcommunitypartners.

4. What strategies are used in the health authorities to prevent early childhood dental disease? What is the most effective combination of strategies?

Programrecords(e.g.,brochures,logicmodel),strategydocumentsorreports.Consultationmeetingnotes.DentalHealthRiskassessmentEnvironmentalScan.

HAstaff/designates(e.g.,DentalHygienists,CertifiedDentalAssistants).

HELPDocumentReview.

HAparticipationinfocusgroup/interview/questionnaire.

-Documentation(descriptive)ofactivitiesforthefirstyearasabaseline.Documentation(descriptive)ofanychangestoactivitiesinfutureyears.

-Healthauthoritystaffandotherprogrampartnersdescribe:-Staffinglevels&roles.-Programpartners&roles.-Similarities&differencesbetweenpreventionactivities&processesacrosslocations/time.-Barriers/facilitatorstoprogramreachandimplementation.-Lessonslearned.Descriptionof-Whatmaybeworkinginareasthathaveintendedoutcomes?-Whatmaynotbeworkinginareasthatdonothaveintendedoutcomes?-Whatwerethecriticalsuccessfactors?-Howcouldtheprogrambeimproved?


APPENDIX B: List of Evaluation Reports, Documents & Maps

ThefollowisalistofallthereportsanddocumentsthatHELPhascreatedduringthefouryearevaluationofBC’sEarlyChildhoodDentalprograms

• LogicModel:BritishColumbiaMinistryofHealthProvincialDentalHealthPrograms,2007

• BCEarlyChildhoodDentalPrograms:EvaluationFrameworkOverview,2007• BritishColumbiaEarlyChildhoodDentalProgram:ProposedEvaluationFramework

(56pages),2006• Analysis&Mappingofthe2006/07BritishColumbiaKindergartenDentalSurvey,

2009• Analysis&Mappingofthe2006/07&2009/10BritishColumbiaKindergarten

DentalSurveys,2011• DentalHealthRiskAssessmentFocusGroups:ProvincialAnalysis,2009• DevelopmentandValidationofaProvincialCariesRiskAssessment(CRA)Tool,2008• DocumentReviewofKeyMessagesinOralHealth-RelatedPublicHealthHandouts,

2008• Analysis&Mappingofthe2006/07BritishColumbiaKindergartenDentalSurvey:

TheAboriginalPopulation[asrequestedbytheFirstNationsHealthCouncil],2008• Dental Health Risk Assessment Focus Groups: Regional Analyses, 2010

- FraserHealth:DentalHealthRiskAssessmentFocusGroups- InteriorHealth:DentalHealthRiskAssessmentFocusGroups- NorthernHealth:DentalHealthRiskAssessmentFocusGroups- VancouverCoastalHealth:DentalHealthRiskAssessmentFocusGroups- VancouverIslandHealth:DentalHealthRiskAssessmentFocusGroups

• Regional Logic Models, 2007- LogicModel:FraserHealthPublicHealthPreventionDentalProgram- LogicModel:InteriorHealthPublicHealthDentalServices- LogicModel:NorthernHealthPublicHealthDentalServices- LogicModel:VancouverCoastalDentalHealthServices- LogicModel:VancouverIslandPublicHealthDentalServices

• Regional Dental Health Risk Assessment Evaluation Project Summaries, 2010- FraserHealth:RegionalDentalHealthRiskAssessmentEvaluationProjectSummary

- InteriorHealth:RegionalDentalHealthRiskAssessmentEvaluationProjectSummary

- NorthernHealth:RegionalDentalHealthRiskAssessmentEvaluationProjectSummary

- VancouverCoastalHealth:RegionalDentalHealthRiskAssessmentEvaluationProjectSummary

- VancouverIslandHealth:RegionalDentalHealthRiskAssessmentEvaluationProjectSummary

• British Columbia Early Childhood Dental Programs Evaluation: Regional Summaries, 2010, 2011- FraserHealth:RegionalSummary- InteriorHealth:RegionalSummary- NorthernHealth:RegionalSummary- VancouverCoastalHealth:RegionalSummary- VancouverIslandHealth:RegionalSummary


Dental Tables and MapsInteractiveDentistLocationMap(includingdrivingdistancetoadentistinBC),2010

Map1.5AboriginalResidentsandDentalStatusinBCHealthAuthorities(requestedbyFirstNationsHealthCouncil),2008

Provincial Dental Mapping Package, January 26, 2011• DentalDecay2006/07• DentalDecay2009/10• DentalDecayChange2006/07-2009/10• PercentNoVisibleDecayExperience(Code01),2009/10• PercentFillingsorOtherRestorations(Code02),2009/10• PercentVisibleDecay(Code03),2009/10• PercentUrgentTreatmentNeeds(Code04),2009/10• BCSchoolDistricts

Provincial Dental Mapping with Socio-economic Status (SES) Overlays, March 22, 2011• KindergartenChildrenwithDentalDecayin2009/10,overlaidwith:

- SESIndexbySchooldistrictin2006- NoHighSchoolGraduationbySchoolDistrictin2006- IncidenceofLowIncomebySchoolDistrictin2005

• KindergartenChildrenwithDentalDecayin2006/07,overlaidwith:- SESIndexbySchoolDistrictin2006- NoHighSchoolGraduationbySchoolDistrictin2006 - Incidence of Low Income by School District in 2005

Interactive Health Authority Maps (Regional Zoomable PDFs), March 22, 2011• FraserHealth:InteractiveHealthAuthorityMap• InteriorHealth:InteractiveHealthAuthorityMap• NorthernHealth:InteractiveHealthAuthorityMap• VancouverCoastalHealth:InteractiveHealthAuthorityMap• VancouverIslandHealth:InteractiveHealthAuthorityMap• AllHealthAuthoritiesInteractiveMap,January26,2011

Neighbourhood Dental Mapping Packages, January 26, 2011• FraserHealth:DentalMappingPackage• InteriorHealth:DentalMappingPackage• NorthernHealth:DentalMappingPackage• VancouverCoastalHealth:DentalMappingPackage• VancouverIslandHealth:DentalMappingPackage


APPENDIX C: Summary of Selected Studies Utilizing the Basic Screening Survey

BasicScreeningSurveysofEarlyChildhoodCaries(ECC)PrevalenceinVariousPopulations

Investigator(s)Region / Country

Sample size Sample demographics Measure Prevalence %

Coteetal.(2006)132

U.S. 224 Refugeesage6mos-18yrs

UntreatedcariesCariesexperienceEarlycareUrgentcare

49515314

11,296 NHANESIIIcomparisonAge2-17

UntreatedcariesCariesexperienceEarlycareUrgentcare

2349193

Lukesetal.(2006)133

Illinois,U.S. 490 Childrenofmigrantandseasonalfarmworkers,Age6-9

UntreateddecayCariesexperienceTreatmenturgency

476612

DentalHeathFoundation(2006)134

California,U.S.

10,949 Kindergartenstudents UntreateddecayCariesexperienceEarlycareUrgentcare

2854215

ConnecticutDepartmentofPublicHealth(2007)135

Connecticut,U.S.

4,315 Kindergartenstudents UntreateddecayDecayexperienceEarlycareUrgentcare

1627120.6

Christensen(2007)136

Colorado,U.S.

3,023 Age5-10yrs(meanage6)

UntreateddecayCariesexperienceEarlycareUrgentcare

2345185

Beltranetal.(1997)137

Georgia,U.S.

632 Age5-12yrs UntreateddecayCariesexperienceRestorationpresentUrgentcare

40594013

Note:AllmeasureslistedabovewerebasedonconsistentindicatordefinitionsfromtheBSSmanual,althoughsomestudieslabeled“Untreateddecay”as“Untreatedcaries”and“Decayexperience”as“Cariesexperience.”“Earlycare”indicatestreatmentrecommendedwithinseveralweeksforcarieswithoutotheroralhealthproblemsorsymptoms.“Urgentcare”indicatestreatmentrequiredassoonaspossibleforpatientsexperiencingpain,infection,orswelling.

132S..Coteetal.,“DentalcariesofrefugeechildrencomparedwithUSChildren,”Pediatrics114,no.6(2004):e733-740.133S.M.Lukes,S.Wadhawan,andL.N.Lampiris,“HealthySmilesHealthyGrowth2004-BasicScreeningSurveyofmigrantandseasonalfarmworkerchildreninIllinois.,”Journal of Public Health Dentistry66,no.3(2006):216-218.134DentalHealthFoundation,“Mommy,ithurtstochew.”The California Smile Survey: An oral health assessment of California’s kindergarten and 3rd grade children.(Oakland,CA,2006).135ConnecticutDepartmentofPublicHealth,Every smile counts: the oral health of Connecticut’s children(Hartford,CT,2007).136MathewChristensen,Colorado oral health survey 2006-2007 school year: Preliminary results.(Denver,CO:ColoradoDepartmentofPublicHealthandEnvironment,2007).137Beltrán,Malvitz,andEklund,“Validityoftwomethodsforassessingoralhealthstatusofpopulations.”


APPENDIX D: Methodological Notes

Data suppressionThekindergartendentalhealthdatacollectedbytheMinistryofHealthwasaggregatedtopreventidentificationofanindividualclient.Datasuppressionisrequiredforanydatasamplewheretherearelessthan5.Assuch,HealthAuthoritieswereinstructedbytheBCMinistryofHealthtosuppress(i.e.,remove)anysensitiveinformationforschoolswherefive(5)orfewerkindergartenstudentsweresurveyed,orincaseswherefive(5)orlessstudentswereassignedtoagivendentalhealthcategory(e.g.,Code01,Code02).Afterthisprocesswascomplete,HAssenttheirschool-leveldentaldatatothemanageroftheEarlyChildhoodHealthandScreeningProgramwithinBCMinistryofHealth,whointurnsentthedatatotheevaluationteamatHELP.Asimilarprocesswasenactedforthe2009/10;however,onlyschoolswithfewerthansix(6)studentssurveyedweresuppressedfromthedataset.

HELP Neighbourhoods NeighbourhoodboundarieswereoriginallycreatedthroughtheconsensusoflocalEarlyChildDevelopmentCoalitionslocatedthroughouttheprovince.HELPwasinstrumentalincoordinatingthisboundarydefinitionprocess,theresultofwhichidentified478sociallyandgeographicallyrelevantcommunitiesinBC.VisibledentaldecaypercentagesforHELPneighbourhoodswerecalculatedbyaggregatingschool-levelinformationintoneighbourhoods.439neighbourhoodsweresurveyedin2006/07and465neighbourhoodsweresurveyedin2009/10.Theanalysispresentedhereinpertainstothelinkeddatabasefile,whichincludescommondataelementsfor437neighbourhoodsthatweresurveyedinbothyearsoftheKindergartenDentalSurvey.Thisnumberislessthantheoriginal478neighbourhoodsbecausenotallneighbourhoodsweresurveyedineachsurveyyearandinsomecases,neighbourhoodsthatweresurveyedinoneyearwerenotsurveyedintheotheryear.

Detailed results of the t-testsApaired-sample t-testwasusedtodetermineiftheoralhealthofchildreninBCwasimprovingovertime,usingHELPneighbourhoodsastheunitofanalysis.Paired-samplet-testscompareneighbourhoodratesofvisibledentaldecaybetweensurveyyearstodetermineifstatisticallysignificantchangeshaveoccurredovertime.Theaveragerateofearlychildhoodvisibledentaldecay(Code02+03)fortheprovincialsampleof437neighbourhoodswas38.8%in2006/07and37.0%in2009/10.Thesetworatesareusedforcomparisonbythepairedsamplest-test.

• Theresultsofthepaired-samplest-test(analysisnotshown,butavailableuponrequest)provideinitialstatisticalevidencethattheoveralloralhealthofBC’skindergartenchildrenimprovedbetweensurveyyears.- Thet-valueof-3.44indicatesthattherateofvisibledentaldecayhasdeclinedbetweensurveyyears(2006/07and2009/10).

- Thep-value=.001demonstratesthestatisticalsignificanceofthisfinding.Inotherwords,wecanbe99.9%certainthatourfindingofanoverallimprovementinoralhealthisaccurate.

• Inadditiontotheoverallprovincialanalysis,aseriesofpaired-samples


t-testswererunforeachofthefive(5)HealthAuthoritiesandsixteen(16)HealthServiceDeliveryAreas(HSDAs).Theanalysisrevealedthefollowingfindings:- Two(2)outoffive(5)HAsshowedstatisticallysignificantimprovementsinoralhealth:theInterior(t=-3.38;p=.001)andVancouverCoastalHealth(t=-5.98;p<.001).

- Five(5)outofsixteen(16)HSDAsshowedstatisticallysignificantimprovementsinoralhealth(seeTable2.1and/orFigure4forreference):KootenayBoundary(t=-2.73;p<.05);NorthShore/CoastGaribaldi(t=-4.18;p<.001);Okanagan(t=-1.88;p<.10);Richmond(t=-2.73;p<.05);andVancouver(t=-2.73;p<.001).

Measuring effect sizeBeyondstatisticaltestsofsignificance(e.g.,t-test),testsofeffectsize(Cohen’sd)measurethemagnitudeorthesizeoftheobservedeffect.Oneadvantageoftestsforeffectsizeisthattheyarenotinfluencedbythesizeofthesample.Thisisimportantbecauseassamplesizeincreases,sodoesthelikelihoodofobtainingstatisticalsignificance.AccordingtoCohen(1988),aneffectsizeof.2issmall,.5ismedium,and.8islarge.

Thecalculatedeffectsizefortheprovincialsampleofn=437isd=.15,whichaccordingtoCohen’stypologyisrelativelysmall.Inotherwords,althoughthedecreaseintherateofprovincialrateofvisibledentaldecayfrom2006/07to2009/10isstatisticallysignificant,theoverallmagnitudeofchangeisrelativelysmall.

EffectsizesforthetwoHAsthatdemonstratedsignificantimprovementsinoralhealthovertimeweremorepronouncedthanfortheprovinceasawhole:d=.35(Interior)andd=.49(VCHA).

EffectsizesforthefiveHSDAsthatweresignificantareasfollows:KootenayBoundary(d=.73);NorthShore/CoastGaribaldi(d=.18);Okanagan(d=.88);Richmond(d=.73);andVancouver(d=.73).

Interpreting the findings of the regression analysisThediagramoppositedemonstratesthepredictedrelationshipsbetweenSES,kindergartendentalhealthandearlychilddevelopment.

Asthediagrampredicts,thesocioeconomicstatusofcommunitiesmayhavedirectinfluencesonbothearlychilddevelopmentandearlychildhoodcaries.Thismodelwasusedtoguidetheanalysisofearlychildhooddentalhealthanddevelopment.

Tables7.1and7.2presentthreepiecesofinformationfortherelationshipbetweeneachSESmeasure(independentvariables)andthe%VisibleDentalDecay(dependentvariable):

Socioeconomic Status

Early ChildDevelopment

Visible DentalDecay


1. The“b” coefficientrepresentstheunstandardizedvalueforbeta,whichistheamountofincreaseinthedependentvariable(%VisibleDentalDecay)forevery1%increaseinthemeasureofSES.Forexample,the%VisibleDentalDecayincreasesby.704%forevery1%increaseinthe%NoHighSchool,controllingfortheeffectsofunionorprofessionalmembership,non-fluencyinEnglishorFrench,low-income,lone-parentfamilies,residentialmobilityandAboriginalidentity.

2. “s.e.”isthestandard error,ortheestimateoftheamountthatourpredictedvaluefor%VisibleDentalDecayis“off”fromtheactualvalueinthepopulation.**Toarriveatat-value,onecouldsimplydivideb/s.e.Thet-valueprovidesatestofstatisticalsignificance.Values+1.96(foratwo-tailedtest)aretypicallyneededtoobtainsignificancelevelofp=.05,whichisdenotedbyanasterisk(*);ifp<.01,twoasterisks(**)areused.

3. ThethirdpieceofinformationinthetableistheImportance Scores,whichrepresenttheamount(%)ofvarianceexplainedbythevariable,relativetoallothervariablesinthemodel.Higherimportancescores(positivevalues)representstrongerrelationshipswiththe%VisibleDentalDecayrelativetotheothervariablesinthemodel.ImportanceScoresarecalculatedasfollows:[(Pearson’sr)*(betaweight)*(100)]/R2foreachvariableinthemodel.ThesumofImportanceScoresis100andnegativescoresindicatethattherelationshipbetweentheSES-measureand%VisibleDentalDecayswitchesitsdirection(from+to–orviceversa)fromthecorrelationanalysistotheregressionanalysis,whichincludesothervariablesintheanalysis.Thisusuallyoccurswhenthecorrelationisinitiallysmall,andthenitchangessignsintheregressionanalysisbecausetheeffectsoftheothervariablesinfluencetherelationship.

IntheanalysisoftheelevenHELPSESsubcomponentsaspredictorsofthe%VisibleDentalDecay,afewmethodologicalconsiderationsweremadetoimprovetheanalysis.SeveraloftheSESsubcomponentswerehighlycorrelatedwithoneanother,whichcanresultinunpredictableresultsduetomulticollinearity.Morespecifically,theSESsubcomponentsforWealth,Education,SocialAssistanceandMedianGovernmentTransferswereallhighlycorrelatedwithoneanother(i.e.,abover=.70).Inaddition,HousingDensitywashighlycorrelatedwithResidentialStability(r=.74).Runningregressionanalyseswhileincludingallofthesesubcomponentsaspredictorswouldreducetheoverallefficiencyofthemodelandcouldleadtoamisinterpretationofresults.Therefore,separatemodelswereruntocompensateforthismulticollinearity:

Model1.WealthwasincludedalongwithUnemployment,ResidentialStability,Poverty,LoneParents,LanguageandImmigration,andWomeninManufacturing,aspredictorsofthe%VisibleDentalDecay.Thisrepresentsour“MainModel.”

Model2.TheWealthsubcomponentwasdroppedfromthemodelandeachofthehighlycorrelatedsubcomponents(Education,SocialAssistance,andMedianGovernmentTransfers)wereenteredasseparatemodelsintheregressionanalysis.

Note:HousingDensitywasdroppedfromtheanalysesaltogetherduetoahighcorrelationwithResidentialMobilityandarelativelylowcorrelationwithdentaldecay(r<.20inboth2006/07and2009/10).


Thismethodologicaltechnique,ofenteringkeyvariablesandremovingothersfromtheanalysis,hastheadvantageofremoving,atleastpartially,thenegativeeffectsofcollinearityfromtheregressionmodels.Thefinalmodelcoefficients(e.g.,F,R2,Std.ErroroftheEstimate)allcorrespondtotheregressionmodelwithWealthincluded.

Interpreting the Early Development Instrument (EDI) Initsdevelopment,theEDIhasundergonepsychometrictestingacrossCanadatoensureitsvalidityandreliability.138OngoingtestingiscarriedoutbothinCanadaandothercountriesthatareusingtheEDI.(Moreinformationandalinktoacopyoftheinstrumentcanbefoundathttp://www.earlylearning.ubc.ca/research/initiatives/early-development-instrument/).

Vulnerabilitydescribestheportionofapopulationwhich,withoutadditionalsupportandcare,mayexperiencechallengesandwhichmaynotfunctionaswellinschoolandsociety.ThedeterminationofvulnerabilityisbasedonEDIscores.Childrenwhoscorebelowthevulnerabilitycut-offonanEDIscalearesaidtobevulnerableonthatscaleofdevelopment.Vulnerabilitycut-offsweresetafterthefirstEDIpilotin1998.WhenthefirstpilotEDIdatahadbeencollected,analysisshowedthat,oneachoftheEDIscales,approximately10%ofthechildrenfittedaprofileofvulnerability.Usingthesedata,thecutoffforeachoftheEDIscaleswasdeterminedusingtherangeofactualscorescollectedandsettingvulnerabilityatthescorethatrepresentedthelowest10%ofthatrange.Thevulnerabilitycut-offscoreshaveremainedconsistentsincetheywerefirstcalculated.HELP’sresearchoverthelast10years,inB.C.andacrossCanada,hasdemonstratedthatthecut-offshavetremendouspredictivecapability:theydoexplainchildren’sschoolexperience,andarehighlycorrelatedwithadolescentandadulthealthandwell-beingmeasuresaswell.

ResultsfromtheEDIareinterpretedonlyatthelevelofthegroup(school,neighbourhood,region,orschooldistrict).Resultsareneverinterpretedattheindividuallevel.Communitiesbenefitfromthisresearchinanumberofways.Theresearchhelpstoshowwheretherearelargedifferencesinchildren’sdevelopment;wheregroupsofchildrenaremoreorlessdevelopmentallyreadyforschoolacrosscommunities,regions,andtheprovince;andhowbroadsocio-economicfactorsmayinfluencechildren’searlydevelopment.Thisinformationcanhelpcommunitymembersbecomemoreawareofwaystocreateenvironmentstohelpchildrenandfamiliesthrive.TheEDIalsoprovidesinformationonchildren’sdevelopmentindistinctpopulations.TrendsinthedevelopmentofchildrenwhoareAboriginalorspeakEnglishasasecondlanguagecanbeanalyzedseparately.Formoreinformationontheinterpretationofresultsforthesegroups,pleasesee:http://www.earlylearning.ubc.ca/research.

138M.Janusetal.,TheEarlyDevelopmentInstrument:population-basedmeasureforcommunities:ahandbookondevelopment,propertiesanduse(Hamilton,Ont.:OffordCentreforChildStudies,2007).


APPENDIX E: HELP SES Scales and Subscales

DataSources:2004TaxFilerand2006Censusdata

Wealth: Families with Children

%familiesreceivinginvestmentincomeorcapitalgains,familieswithchildrenunder18%familiesdeclaringcharitabledonations,familieswithchildrenunder18%familiesreceivinginvestmentincomeorcapitalgains,familieswithchildrenunder6%familiesdeclaringcharitabledonations,familieswithchildrenunder6%familiesdeclaringcharitabledonations,lonefemalefamilieswithchildrenunder18%familiesdeclaringcharitabledonations,couplefamilieswithchildrenunder18%familiesreceivinginvestmentincomeorcapitalgains,couplefamilieswithchildrenunder6%offamiliesdeclaringcharitabledonations,couplefamilieswithchildrenunder6

Unemployment

Employmentrate,childrenunder6Femaleunemploymentrate,females15andupFemaleunemploymentrate,females25andupMaleemploymentrate,childrenanyageMaleemploymentrate,childrenunder6Participationrate,25andupUnemploymentrate,childrenunder6Unemploymentrate,all15andupUnemploymentrate,all25andup

Residential Stability%movedinlastyear%ofnon-migrantmoversINLAST5YEARSHomeownershipratePoverty:WomenOnlyEarners%heterosexualfamilies,femaleonlyemploymentincome,familiesw/nounder18%heterosexualfamilies,femaleonlyemploymentincome,familiesw/childrenunder18%heterosexualfamilies,femaleonlyemploymentincome,familiesw/childrenunder6

Lone Parents%loneparentfamilies%lonefemalefamilies%lonemalefamiliesShareofalllonemotherfamilieswithchildrenunder18inentirepopulationShareofalllonemotherfamilieswithchildrenunder6inentirepopulation

Housing Density PercentageofsingledetachedhousesPercentageofapartmentthathas5ormorestoriesPercentageofapartmentthathasfewerthan5stories

Language and Immigration%BuddhistsNumberofnon-Christianreligions,1%ofpoporgreater%3rdormoregeneration15yrsandover%firstgenerationCanadians%immigrantswhoarrivedbefore1961%immigrantswhoarrivedbefore1991and1995%immigrantswhoarrivedbefore1996and2001%immigrantswhoarrivedbefore1961and1970%ofpopwithCanadianCitizenship%oftotalpopthatimmigratedbetween1996-2001%homelanguageEnglish%ofpopwithEnglishasmothertongue%ofpopwithnon-officiallanguageasmothertongue%usingforeigninhomelanguage%visibleminority


Women in Manufacturing

%womeninmanufacturingpositions

Education%ofpeopleaged20andolderwithauniversitydegree%ofpeopleaged20andolderwhohavenotgraduatedfromhighschool

Social Assistance %familieswithyoungchildrenreceivingsocialassistance%familieswithoutyoungchildrenreceivingsocialassistance

Median Government TransfersMedianamountofgovernmenttransfers,forfamilieswithyoungchildrenMedianamountofgovernmenttransfers,forfamilieswithoutyoungchildren

Creation of the HELP SES Index ForeachofthevariableswithintheHELPSESIndexandComponents,astandardscorewascalculatedforeachneighbourhoodinBC.Forsomevariables,wherehigherscoresareassociatedwithlowersocio-economicstatus,thesestandardscoresthenhadtobe“reversed”(i.e.,thesignwaschanged)tomaintainconsistencyintheIndex(i.e.,allSESmeasurescodedsoastobe“protective”factorsinrelationtokindergartenvisibledentaldecay).Unemploymentandloneparenthoodaretwoexamplesofvariableswherethescoreswerereversed.Foreachcomponent,themeanofthestandardizedscoresofthevariablesinthatcomponentwascalculatedforeachneighbourhood.Sincethemeanforeachvariableoveralliszero,themeanofthesecomponentscoresisalsozero.However,thestandarddeviationofthesecomponentscoresislessthan1becauseoftheaggregationoverseveralstandardizedindividualvariables.Thesemeancomponentscoreswerethenstandardizedtohaveastandarddeviationof1.TheSESIndexwasthenconstructedbytakingthemeanofthesestandardizedcomponentscores.Again,theaggregationprocessresultsinanIndexwithanoverallmeanof0,butastandarddeviationoflessthan1,andsoasafinalstep,theHELPSESIndexwasstandardizedbysettingtheoverallstandarddeviationto1.


APPENDIX F: Key Messages In Oral Health-related Public Health Handouts

Fivemainthemesemergedfroma2007/2008reviewofBCpublichealthhandoutsrelatedtooralhealthandnutritionforchildrenunder6:

1) Dentist visits.Withinthedentalvisittheme,theprimarymessagewasthatachildshouldhavethefirstdentistvisit6monthsaftertheappearanceofthefirsttoothoraroundageoneandthenseeadentistevery6to12months.

2) Signs of decay.Therewassomeoverlapbetweenthedentalvisitanddecaythemesasakeymessageunderthedecaythemewastocheckababy’smouthoncemonthlyforsignsofdecay,suchaswhiteorbrownspotsontheteethparticularlynearthegumline,andtoseeadentistifdecaywassuspectedorvisible.Thesecondkeymessagewithinthedecaythemerelatedtobacterialtransferencefromcaregivertochild.Handoutsinformedparentsthatbacteria,someofwhichcausetoothdecay,begintogrowuponappearanceofachild’sfirsttooth.Advicetoreducetheriskofbacterialtransmissionincludedusingseparatetoothbrushesandspoonsaswellaswashingasootherinwaterratherthanlickingittocleanit.Inaddition,caregiverswereadvisedtouseafluoridetoothpastethemselvesandtoensurethattheirowndentalworkwasuptodate.Onehealthauthorityhadhandouts,whichnotedthatwhencaregiversofyoungchildrenchewgum-containingxylitol,fewerbacteriaweretransmittedtochildren,andthosechildrenhadfewercavities.

3) Tooth brushing and fluoride.Manyhandoutsaddressedtoothbrushingandfluoridetoothpasteuseindetail.Thisthemealsoincludedinstructionstocleanababy’sgumstwicedailywithaclean,dampfaceclothpriortotheappearanceofteeth.Oncethefirsttoothappeared,parentsweretouseasoftbabytoothbrushwithasmearoffluoridetoothpastetobrushteethtwicedaily,inthemorningandbeforebedtimeafterthelastbreastfeed,bottleorfood.Theamountoftoothpasteusedwastobeincreasedtoapea-sizedamountatage3to6yearsasmolarsappearedandanteriorteethfinishedcomingin.Flossingwastocommencewhenteethweretouching.Informationinthehandoutsinformedparentsthatchildrenwouldnotbeabletocleantheirownteethuntilaroundage6to8years,whentheyalsogainedthecapabilitytowritetheirownname.Thepurposeofthefluoridetoothpastewasnotedtobeforthepreventionofcariesbyhelpingteethbemoreresistanttoacidsfromfoodsandcavitycausingbacteria.Fluoridevarnishwasrecommendedfor:childrenwhohadwhitespotlesions,previouscariesexperience,orcurrentoralcaredifficulties;childrenwhosleptwithabottlecontainingaliquidotherthanwater;childrenwhodidnothavetheirteethcleanedtwicedailywithafluoridetoothpaste;orchildrenwhoseprimarycaregiverhadhaddecayinthepast12months.

4) Feeding practices.Drinkingandfeedinghabitsrelatedtodentaloutcomeswasanotherpopularthemecoveredinmanyhandouts.Areoccurringmessagewasthatthelengthoftimeasugar-containingbeverageorfoodisincontactwithteethisafactorfortoothdecay.Forexample,manyhandoutscommentedthatachildwhosleptwithabottlecontainingaliquidotherthanwaterwasatriskfortoothdecay.Listsofsugar-containingbeverages,suchascow’smilk,formula,fruitjuiceandsweeteneddrinks(e.g.icedtea,pop,lemonade)werereportedinnumerous


handouts.Theuseofaclean,wetclothtowipebaby’smouthafternursingwasadvised.Stickyfoods,suchasteethingcookiesandbiscuitswerenotrecommendedbecausetheyremainonteethforlengthyperiodsoftimeandprovideaneasilyaccessiblesubstrateorfoodforcavitycausingbacteria.Puttingsugar,honeyorcornsyruponasootheralsowasadvisedagainst.Inaddition,frequentsipping(liquidsotherthanwater)andeatingduringthedaytimealsowasnotedtobeariskfortoothdecay.Becauseitdoesnotcausetoothdecay,waterwassuggestedasathirstquencherbetweenmealswithmilkandjuicereservedformealandsnacktimes.Finally,informationfromanumberofhandoutsrecommendedswitchingfromabottletoacupstartingat6to9monthsofagewithcompletionoftheswitchby12to14monthsofage.

5) Barriers to access.Barrierstoaccesswasalesscommonlyoccurringthemeamongthehandouts.Forexample,onehealthauthorityhadacoupleofhandoutsthatdescribeddentalprogramsavailabletovulnerablepopulations,suchasfamiliesonPremiumAssistancethroughtheirmedicalplan,clientsoftheMinistryofHumanResourcesorMinistryofChildrenandFamilyDevelopment,Aboriginalchildrenwithastatusnumber,orchildrenfromlow-incomefamilies,whowereinneedofurgentcareduetopain,infectionorseveredecay.