Evaluation of a Bright Futures Oral Health Intervention
Condition: Health Knowledge, Attitudes, Practice
Study type: Observational

Summary: 
      Pediatricians serve an important role in promoting health in families. Bright Futures offers
      a child and family-centered approach to health promotion in incorporating partnership and
      communication skills of providers. Two areas of importance are in promotion of oral health
      and prevention of iron deficiency. We plan to study implementing educational curriculum to
      pediatric residents through a randomized controlled trial. Randomization will be done through
      assignment at the level of pediatric training program. Residents randomized to Group 1 will
      receive education about Bright Futures partnership and communication skills with oral health
      as the main health promotion topic. Group 2 will receive educational curriculum pertaining to
      the topic of iron deficiency prevention. While pediatricians are positioned perfectly to
      partner and effectively communicate with families on these two issues, there are gaps in
      pediatric education addressing these topics. The CORNET continuity practices of the
      Ambulatory Pediatric Association provide a venue through which multiple residency programs
      that educate pediatric residents and whose residents provide medical care to underserved
      children can participate. The research hypotheses include:

        1. Residents in Group 1 will have greater confidence, knowledge and competence in
           partnership building and communication with families

        2. Residents in Group 1 will have greater knowledge and competence in discussing oral
           health promotion

        3. Residents in Group 2 will have greater knowledge and competence in discussing iron
           deficiency prevention

        4. Parent-child dyads in Group 1 will be more likely to have established a dental home

        5. Parent-child dyads in Group 1 will be more likely to be satisfied with their healthcare
           encounter.

      Pediatric practices provide fertile ground for the provision of health promotion on oral
      health and iron deficiency prevention. However, evidence for the effectiveness of primary
      care clinician interventions of screening, referral and counseling to prevent dental caries
      is lacking [14]. The National Survey of America's Families [15] found 47% of children did not
      receive the recommended number of dental visits, with the youngest ones being least likely to
      receive any dental care.

      Although 90% of pediatricians agreed they had important roles in identifying and counseling
      patients on prevention of caries, half stated they had received no previous training during
      medical school or residency and their knowledge of basic oral health topics was limited [13].
      These studies highlight that pediatricians play important roles in oral health and are
      capable of being trained to complete oral screening exams, but more education and guidance is
      needed.

      Iron deficiency is the most common childhood nutritional deficiency in the United States.
      Recent prevalence data have determined that 7-30% of children in the United States aged 1-2
      years have iron deficiency and 3-10% have iron deficiency anemia [17, 18]. Specific goals in
      Health People 2010 include a reduction of iron deficiency to 5% in children less than 3 years
      of age.
    

Detailed description: 
      Although health professionals must be equipped to promote healthy lifestyles and serve as
      resources for the public's health information, many gaps in the education and training of
      residents exist. Health professional students readily admit to deficiencies in their training
      (i.e. lack of learning principles of prevention, health promotion, behavior change and risk
      reduction), yet, curricular changes have been slow [1,2]. A 1997 AAMC Medical School
      Graduation Questionnaire revealed that almost one quarter of graduates felt instruction time
      devoted to health promotion and disease prevention was inadequate [3, 4, 5, 6]. Mandates for
      competency-based, post-graduate training by the ACGME Outcomes Project and competency
      expectations by the AAMC Medical Schools Objectives Project (MSOP) require all residency
      programs and medical schools to develop innovative approaches to teaching clinical skills.

      We believe the resident continuity experience is the perfect venue to implement and practice
      clinical guidelines and Bright Futures concepts. Past studies have documented that residents
      in academic, hospital-based sites, similar to those in CORNET, experience the most continuity
      and longitudinal relationships with their patients [7, 8, 9]. Longitudinal learning is a
      basic tenet of successful interventions and is easily accomplished during resident continuity
      practice. Pediatrics in Practice provides key resources for enhancing knowledge in
      family-centered oral health promotion and responding to the present gaps in medical education
      and training. Both residents and pediatricians in practice have limited knowledge of Bright
      Futures and its tenets. Bright Futures: Guidelines for Health Supervision of Infants,
      Children, and Adolescents represents the framework of providing contextual care to children
      that fosters partnerships among families, health professionals, and communities and increases
      knowledge about health education and prevention [10, 11, 12]. Although more competency-based
      curricula are being designed to promote skills and knowledge in health promotion and
      preventive services, there has been very little research into their efficacy in trainees.
    

Intervention name(s): Group 1: Bright Futures Oral Health Curriculum; Group 2: Iron Deficiency Training Module
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Residents who are randomized to Group 1 will receive a resident curriculum that exposes them to Bright Futures concepts of health promotion, including partnership building, communication and oral health. Group 1 residents will complete 7 modules, 3 on Bright Futures concepts (health, partnership building and communication), and 4 on oral health promotion. These modules have been developed in collaboration with the Pediatrics in Practice workgroup and the Open Wide modules endorsed by the American Academy of Pediatrics and the Maternal and Child Health Bureau. The oral health modules address dental caries development and prevention, importance of identifying maternal oral health status, duration of bottle-feeding or breastfeeding and discouraging both during sleep.; Our study team opted to include a single 1-hour educational module addressing the identification and prevention of iron deficiency created by the AAP on Pedialink® to the active control group. This educational module addresses screening for and assessing risk for iron deficiency.
Observational model: Cohort
Time perspective: Cross-Sectional
Sampling method: Non-Probability Sample
Study population: 
        Pediatric categorical residents in continuity clinics associated with CORNET practices that
        volunteer to participate will be asked to participate in the study. Resident inclusion
        criteria will include pediatric residents in their 1st or 2nd year of categorical training.
        Parent-child dyad inclusion criteria include children between 12-35 months of age,
        accompanied by a legal guardian, who presents for a scheduled health maintenance visit with
        their primary care provider who is a pediatric resident. Families must have a means by
        which to be contacted (i.e., telephone, cell phone, or beeper number) for follow-up. At
        least 2 numbers for communication will need to be solicited.
      
Keywords: Pediatric oral health; Bright Futures; Health promotion