# Presentation: 581057

## Indian Health Service: A Systems Approach to Health Care

- Candace Jones, MPH
- Director, OHP/DP, IHS

**Notes:**
The Indian Health Service is the principal federal health care provider and health advocate for approximately 1.5 million American Indians and Alaska Natives living on or near reservations.  Historically tribes have been the political and social framework for decision making.  Health care and education facilities are often the glue that holds families and communities together.  

The health of AI/AN people lags behind the all U.S. population groups in most indicators.  The focus of this presentation is directed toward the oral health of Indian people and more specifically toward its future leaders - children 0 to 17 years. 

## How are data collected?

- Annual Workload Data
- Health Outcomes Codes
- Periodic Oral Health Surveys

**Notes:**
The IHS has historically collected various types of data on the population.  The dental program collects workload data by provider and by location on all services provided in clinical settings.  Services are also provided in other settings such as schools and day care centers.  

Codes have also been created to measure health status indicators such as a child with no experience of dental decay or a child with a molar sealant, etc.  

Since 1984, the IHS has completed three program-wide oral health surveys through a convenience sample of clinic users.  These data provide trends analysis and comparability to U.S. general populations. 

## How are data used? 

- Program Management
- Reports to the Congress
- Requests from advocacy groups

**Notes:**
These data are used to manage individual local programs as well as compiled national data to manage the entire program and provide consultation to tribal governments.  

These data are also provided to the Congress to assure  accountability and performance for Federal resources.  

While the IHS cannot lobby the Congress, there are various  groups (Friends of IHS) that use the information to advocate for the many health care needs of the first Americans. 

## Pediatric Performance Measures in IHS

- Increase utilization of dental care system
- Increase sealants in 8 and 14 year olds

**Notes:**
The IHS is accountable as a federal agency to the Congress as well as to the Indian people which we serve.  During the last five years, the IHS has used national health care indicators such as Healthy People 2000 as well as specific program indicators for the agency based on the  Government Performance and Results Act (GPRA) in order to document progress and measure changes in the oral health status of children.  The IHS dental program has promoted 4 indicators for all programs to focus their efforts.  These indicators include: 

1.  Increasing access for children to the health care delivery system
2.  Increasing sealants in children 8 and 14 years

## Pediatric Performance Measures in IHS

- Reduce caries experience & untreated decay
- Increase access to community water fluoridation

**Notes:**
as well as 

3.  Reducing the amount of new and untreated  tooth decay in children, and 
4.  Increasing access to community water fluoridation. 

## Utilization of Health Care System - Ages 2-17 years

**Notes:**
The biggest problem facing AI/AN people is a lack of access to the health care delivery system.  Only about 1 in 4 Indian children received a dental visit in the last fiscal year. 

In comparison, approximately 73 percent of all U.S. children ages 2 to 17 years received a dental visit in the last year. 

## Sealant Use in Indian vs. U.S. Children

**Notes:**
In the 1999 oral health survey conducted by the IHS, approximately half of children ages 8 and 14 years had at least one molar sealant as compared to 23 and 15 percent of U.S. children in these same age cohorts respectively.   

The IHS has promoted the use of dental sealants since the mid 1980s and have noted caries experience in school-age children to have declined during this time.  

Many children have received sealant and oral screenings in school settings over the last 20 years.  These sealant programs also serve to identify those children who need referrals to the dental clinic for more complex care.  

## Caries Experience – Indian vs. U.S. 2-4 Year- Old Children 

**Notes:**
According to data from the 1999 oral health survey, preschool age Indian children have experienced some of the highest decay rates in the world.  This bar graph shows that Indian children have 4-5 times the prevalence of tooth decay and untreated tooth decay when compared to all U.S. children in this age group.  

## Caries Experience – Indian vs. U.S. 6-8 Year-Old Children

**Notes:**
Ninety percent of 6-8 year old Indian children have experienced tooth decay and 69% have untreated decay which are almost twice the rates of all U.S. children in this age cohort.  While much effort has been placed on use of dental sealants, there is still  a great amount of decay in this population.  Some of the contributing factors are diets high in refined sugars and lack of exposure to protective factors such as fluoride (in the water, in toothpaste, and in mouthrinses).  

## Caries Experience – Indian vs. U.S. 15 Year-Old Adolescents

**Notes:**
For 15-year old Indian adolescents, the picture is similar to the 6-8 year old population, although 60% of the all US population has experienced dental decay by the age of 15 years. However, untreated decay is about 3 times greater for Indian adolescents than all U.S. 15-year olds. 

## Access to Community Water Fluoridation

**Notes:**
While about 62 percent of the US population has access to community water fluoridation,only about 25 percent of AI/AN people have access to this important public health benefit.  We are working with tribal utilities to raise the compliance of the number and effectiveness of water systems which monitor the fluoride levels in the water.  Changes in tribal management, revised recommendations by the Centers for Disease Control and Prevention (CDC), and downsizing of Headquarters and Area staffs have accounted for some of the reduction in the number of Indian people served by community water fluoridation.  In FY 01, the IHS Dental and Environmental Health programs will be putting additional resources into fluoridation efforts. 

## A Systematic Approach To Health Care Delivery

- Prenatal care includes dental
- Well Baby Check-ups & Referrals
- Women, Infant and Children Nutrition Programs on reservation

**Notes:**
Oral health services are delivered in hospitals and health clinics located on or near reservations and as such are integrated into primary health care.  For example, prevention of Early Childhood Caries includes prenatal oral health care.  Children are seen on routine basis for health care and are also referred to the dental clinic for oral health examinations and care.  Dental staff work closely with pediatric and general physicians and nurses to assure that dental care is part of general health care.  We also provide training to the Women, Infant and Children (WIC) nutrition program staff so they can include information on oral health as part of their nutritional counseling services for their Indian clients.  

## A Systematic Approach To Health Care Delivery

- Early Head Start & Head Start priorities
- Schools on reservations
- Community Health Aids & Representatives
-  Public Health Nurses

**Notes:**
It is recommended that children have their first dental visit at one year of age.  Head Start and Early Head Start (infants birth to three years and pregnant women) programs present  a great opportunity to provide health care information, screenings and referrals so that children receive the oral health care they need.  Children in these programs are given priority in obtaining services in most IHS clinics.  Schools are generally located on the reservation and in close proximity to the health clinics and hospitals.  The dental staff work with school administrators and teachers to gain access to children for screenings, placement of dental sealants, referrals as needed and provision of oral health education.  Toothbrushing programs as well as weekly fluoride mouthrinse programs are also encouraged. 

Community health aids and representatives are members of the local tribe and receive training on a variety of health care issues including oral health promotion and disease prevention services and can serve as case managers in many programs.  Public health nurses are another health care provider that make home visits and can provide important messages and referrals for oral health care.  

## Summary 

- Great oral health disparities exist
- Integrated services approach is useful
- Community and public health perspective emphasized
- Partnerships are key

**Notes:**
As you have heard, the oral health disparities are great between Indian children and all U.S. children.  One of the benefits to Indian families is an integrated primary care approach to disease prevention and health promotion. While most services are provided in a clinical setting, the collaboration with Head Start staff, day care programs, schools and other community gathering places all offer  opportunities to provide additional preventive, educational and referral services.  

A public health approach of providing the greatest good to the greatest number of people at the least cost and acceptable to the community has been historically embraced by the Indian Health Service.  As tribes are taking over more of the management of their programs, the resources and allocation of health care services has generally improved.  Creating partnerships in the community among health professionals, academic institutions, businesses, foundations and Indian people is the key to improving the overall health of American Indian and Alaska Native people. Raising the educational and economic levels of community members through these similar partnerships is also paramount to improvements in all health indicators.  It really does take a village to raise a child.