A Scoping Review of Oral Health Outcomes and Oral Health Service Utilization of 2SLGBTQ+ People

BACKGROUND

Oral health is an integral aspect of overall well-being and quality of life. Population groups such as two-spirit, lesbian, gay, bisexual, transgender, and queer, including other sexual and gender minorities (2SLGBTQ+), have reported poor oral health outcomes. Therefore, the aim of this review was to investigate the extent and scope of the literature describing 2SLGBTQ+ oral health outcomes, including unmet oral health needs and patterns of oral health care service utilization, as well as the risk factors affecting both.

METHODS

A comprehensive search strategy was developed to review the scope of the literature pertinent to unmet oral health needs and factors affecting access to oral health care among 2SLGBTQ+ members, globally. In total, 6 databases were searched with a combination of keywords relevant to 2SLGBTQ+ oral health status and oral health care utilization.

RESULTS

Our review identified 10 studies that met the eligibility criteria. Five out of 10 studies were based in India, 4 in the United States, and 1 in Brazil. Two studies reported poorer oral health outcomes among transgender people as compared with cisgender people, while 2 studies reported similar patterns of dental service utilization between their transgender and cisgender participants. Five studies explored the personal and structural risk factors associated with poor oral health outcomes, including financial affordability and income level and perceived discrimination, including instances of misgendering in health care settings. However, further comprehensive studies must be conducted to validate the trends and findings reported by the studies in the review and to generate data from diverse regional contexts.

CONCLUSIONS

Our review identified that the extent of the literature in this research area is sparse and scarce. The evidence indicates poorer oral health status among 2SLGBTQ+ communities. Wider studies with diverse, representative samples are required to gain a comprehensive understanding of 2SLGBTQ+ oral health outcomes.

KNOWLEDGE TRANSFER STATEMENT

The results of this review will undoubtedly be important for many years to come as 2SLGBTQ+ oral health equity is prioritized by experts in public health dentistry. This review will allow other researchers to understand and fill literature gaps regarding 2SLGBTQ+ oral health outcomes, furthering this area of research.

Application Status Among Women Enrolled in a Healthy Start Program in Arkansas for the Special Nutrition Program for Women and Children

This study aimed to examine the demographic characteristics of pregnant women in a Healthy Start program who are presumed eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), but who have not yet applied for WIC benefits. We used a cross sectional evaluation of data collected from pregnant women (n=203) participating in a Healthy Start program. Data came from surveys administered at enrollment in the Healthy Start program from July 15th, 2019 until January 14th, 2022. The primary outcome was WIC application status, which was determined by whether the woman had applied or was receiving benefits at the time of enrollment. Covariates included race/ethnicity, marital status, insurance, education, income, age, employment, and having previous children/pregnancies. Fisher exact tests and logistic regression were used to examine associations. Approximately 65% of women had not yet applied for WIC benefits. Marshallese women (80.9%) and other NHPI women (80.0%) had the highest need for assistance. In adjusted analyses, White women (p = 0.040) and Hispanic women (p = 0.005) had lower rates of needing assistance applying for WIC than Marshallese women. There were higher rates of needing assistance in applying for women with private insurance or with no insurance and for those with higher incomes. Nearly two out of every three pregnant women who were eligible for WIC had not yet applied for benefits. The findings highlight the need for outreach for all populations that may be eligible, particularly among racial/ethnic minorities and those with higher incomes.

Acculturation and Dental Care-Related Anxiety: An Exploratory Assessment from the Hispanic Community Health Study / Study of Latinos

This study aimed to determine the associations between acculturation, dental anxiety, and dental utilization among Hispanics/Latinos living in the US. A proxy measure of dental anxiety was available for 7539 adults who had not visited a dentist within the last year. All completed the Short Acculturation Scale for Hispanics (SASH). Bivariate logistic regression and adjusted multivariable logistic regression analysis were conducted. Approximately 22% of the sample was dentally anxious. Dental anxiety was significantly associated with SASH language scale score (OR 1.09, 95%CI 1.02, 1.18, p = 0.04), years in US (OR 1.53, 95%CI 1.23, 1.91, p < 0.0001), and preferred Spanish language (OR 1.30, 95%CI 1.05, 1.63, p = 0.0192); lower acculturation corresponded to higher dental anxiety. Adjusting for sex, age, education, income, insurance, and oral health status, level of acculturation was associated with dental anxiety (AOR 0.87, 95%CI 0.75, 0.91, p = 0.009), but neither were associated with utilization. Acculturation may be an important predictor of dental anxiety for Hispanics/Latinos living in the US.

Evaluating Trust in the Patient-Dentist Relationship: A Mixed-Method Study

BACKGROUND

The objective of this article was to understand the trust of study participants in dental providers and trust-building practices used by dentists to establish and maintain trust with their patients.

METHODS

This study used a concurrent cross-sectional mixed-methods design to measure the participants' trust in their dental providers. An 11-item Dental Trust Scale (DTS) questionnaire was administered to 150 White, Black, and Hispanic study participants. In addition, the research team conducted semistructured interviews with 7 dentists in order to understand their perspectives related to patient trust. The internal consistency of the DTS was tested using Cronbach's α. Univariate and multivariable logistic regression models were run to test the association between the DTS mean score and individual participant factors. Qualitative information from interviews was analyzed using a thematic analysis approach.

RESULTS

The overall mean score of dental trust for the entire sample was 3.4. The DTS had good internal consistency (α = 0.93). Overall, dental trust was significantly higher in participants who had a regular dentist (F = 8.74, P = 0.003). The qualitative data were grouped under these key thematic categories: the importance of trust, building trust, and trust in treatment planning. Qualitative analysis also showed that the 2 main trust-building tools used by dentists were communication and understanding the patient's lifestyle or social determinants of health.

KNOWLEDGE TRANSFER STATEMENT

This study provides insight into the dentist-patient relationship. It increases our understanding of levels of dental trust among patients and examines methods used by the dentist to build trust. The outcomes of this study can be considered by dentists in their everyday practice as they seek to build trust with their patients.

Determinants of Tooth Loss in a Medicaid Adult Population

BACKGROUND

The objective of this retrospective cohort study is to examine the determinants of tooth loss in a Medicaid-enrolled population using claims data from 2016 to 2018.

METHODS

Deidentified administrative claims data for Medicaid-enrolled adults between the ages of 50 and 90 y in 2016 to 2018 were examined using the IBM Watson MarketScan Medicaid Database. The sample size was 91,468. The entire sample was divided into 2 cohorts: no tooth loss cohort (n = 54,786) and tooth loss cohort (n = 36,682). The tooth loss cohort was further divided into 2 groups: 1 to 5 teeth lost (n = 29,141) and 6 or more teeth lost (n = 7,541). Tooth loss was described by age, gender, race, number of commodities, and if periodontal treatment was performed. Logistic regression models were conducted to examine factors associated with tooth loss.

RESULTS

Within the tooth loss cohort, the patients who had periodontal treatment had higher odds of losing at least 1 tooth (odds ratio [OR], 1.15; confidence interval [CI], 1.10-1.20) and lower odds of losing 6 or more teeth (OR, 0.25; CI, 0.22-0.29). In the regression analysis, the predictive margins of tooth loss for 1 tooth and 6 or more teeth follow a linear path. Compared to no comorbidities, the odds of losing 6 or more teeth increased with 1, 2, or 3+ comorbidities.

KNOWLEDGE TRANSFER STATEMENT

This study provides significant information about the quantification of comorbidities and its direct correlation with the increased odds of tooth loss. This study also highlighted the protective effect of periodontal treatment on tooth loss. This knowledge can be useful to dental care providers to understand the risk of tooth loss in their patient population.

Design and Development of High Power Broad Band Dry RF Load

High power S-Band ferrite based RF load is designed and developed which is capable of handling 3 kW average power at operating frequency 2998±20 MHz . Electrical and thermal design is carried out using CST Studio Suite. Mechanical parts are fabricated according to the design. Water cooling is provided to the absorbing ferrites to support high power operation. Various RF load parts are fabricated, chemically cleaned and brazed. The experimental return loss better than 30 dB for a bandwidth of 250 MHz is achieved. The numerical and experimental results are discussed and presented in this paper.

Oral Health of African Immigrants: A participatory approach to needs assessment

OBJECTIVE

Dental care service use is lower in the immigrant population in the US, with the African immigrant population increasing at a much higher rate. We aimed to evaluate the barriers faced by the African immigrant community through a participatory needs assessment approach.

METHODS

Photovoice, a qualitative research method was used to collect the data. Thirty participants were recruited from community events, churches, and African community-serving organizations. Participants took photographs related to oral health research questions. Focus groups were conducted with the participants to discuss the clicked pictures. The focus group data were transcribed and analyzed using an inductive and thematic approach using Atlas Ti®.

RESULTS

The response rate was 90% and six focus groups were conducted. Focus group data demonstrated participants' knowledge of good oral health and preventive oral behaviors; physical, financial and psychosocial barriers to accessing dental care; and cultural and social beliefs of the community. The participants had good knowledge about oral hygiene habits and dietary factors impacting the oral health of their community. Several barriers including, lack of perceived oral health needs, transportation, time, insurance, fear, and trust were identified that prevent them to access dental care.

CONCLUSION

Further research is warranted to understand the cultural norms and perceived needs of the African immigrant community. Increasing our understanding of such knowledge can support in improving the cultural competency of the oral health workforce.

Migrant and refugee Oral Health

This issue contains two papers on the oral health of migrant people. The oral health of migrants, refugees, and asylum seekers is often worse than the general oral health of the host country's population (Crespo, 2019; Davidson et al., 2006). Poor oral health outcomes in migrants are due to a combination of upstream, psychosocial, and behavioral factors. Migrant communities might then have vital priorities that compete with oral health. Consequently, they may express lower needs and may not focus on oral health; all these factors lead to a higher risk of developing dental diseases. Lack of oral health services is commonly seen due to limited fi nancial resources or lack of dental providers in the vicinity of migrant communities or refugee camps. They face ad- ditional cultural and linguistic barriers in navigating the health care system of a new country.

What Can We Learn from Parents of Caries-Free and Caries-Active Hispanic Children?

OBJECTIVE

This study evaluated strength-based motivators within Hispanic families that support the creation of health in their children. A mixed-methods approach was used to understand differences in Hispanic parental factors between caries-free (CF) and caries-active (CA) children.

METHODS

A cross-sectional survey was conducted with 200 parent-child triads (primary child: between 0 and 6 y; reference child: between 0 and 10 y) recruited from health centers in the Denver Metro area. All the participating children received an oral examination, and the triads were grouped as CF or CA based on the caries status of the primary child. Qualitative data were collected through in-depth individual interviews with the parents. The analysis only involved the primary child. Bivariable analysis were conducted between parent factors (independent variables) and presence or absence of caries (outcome variable). The variables with P < 0.20 in the bivariable analysis were subjected to 2 multivariable logistic regression models. The children in the CF group had mean (SD) age of 2.8 (1.28) y compared to the CA group at 4.0 (1.55) y (P < 0.001). Bivariable analysis demonstrated that parents in the CF group reported higher oral hygiene behavior scores (P = 0.047), perceived fewer barriers (P = 0.009) to accessing preventive dental care, and considered their children more susceptible to cavities (P = 0.001) compared to parents in the CA group. Multivariable model (adjusting for socioeconomic characteristics) demonstrated that parents of CF children perceived high susceptibility to caries for their children (P = 0.040). Multivariable model (adjusting for acculturation) demonstrated an association of parental oral hygiene behavior (P = 0.040) and parent-perceived susceptibility to caries (P = 0.010) with CF child status. Qualitative interviews revealed that parents in the CF group were concerned about their children's higher susceptibility to caries and tried to establish good oral hygiene routines for their children.

CONCLUSION

The results of this study demonstrated that parental behaviors and health beliefs could be significant determinants of caries status in Hispanic children.

KNOWLEDGE TRANSFER STATEMENT

Results of this study indicate that parental oral health beliefs and behaviors are significant determinants of caries status in children of Hispanic population. Parental beliefs could motivate them to take action or establish behavior that prevents dental caries in their children. Health care providers and caries prevention efforts can incorporate this information to tailor oral health promotional messaging and approaches to improve the oral health of Hispanic children.

Gender Inequalities in the Dental Workforce: Global Perspectives

The aim of this review is to investigate the growth of diversity and inclusion in global academic dental research with a focus on gender equality. A diverse range of research methodologies were used to conduct this review, including an extensive review of the literature, engagement of key informants in dental academic leadership positions around the world, and review of current data from a variety of national and international organizations. Results provide evidence of gender inequalities that currently persist in dental academics and research. Although the gender gap among graduating dental students in North America and the two most populous countries in Europe (the United Kingdom and France) has been narrowed, women make up 30% to 40% of registered dentists in countries throughout Europe, Oceania, Asia, and Africa. In academic dentistry around the globe, greater gender inequality was found to correlate with higher ranking academic and leadership positions in the United States, United Kingdom, several countries in European Union, Japan, and Saudi Arabia. Further disparities are noted in the dental research sector, where women make up 33% of dental researchers in the European Union, 35% in North America, 55% in Brazil, and 25% in Japan. Family and societal pressures, limited access to research funding, and lack of mentoring and leadership training opportunities are reported as also contributing to gender inequalities. To continue advancing gender equality in dental academia and research, efforts should be geared toward the collection and public dissemination of data on gender-specific distributions. Such evidence-driven information will guide the selection of future strategies and best practices for promoting gender equity in the dental workforce, which provides a major pipeline of researchers and scholars for the dental profession.

Empowering Women Researchers in the New Century: IADR's Strategic Direction

Gender inequality in science, medicine, and dentistry remains a central concern for the biomedical research workforce today. Although progress in areas of inclusivity and gender diversity was reported, growth has been slow. Women still face multiple challenges in reaching higher ranks and leadership positions while maintaining holistic success in these fields. Within dental research and academia, we might observe trends toward a more balanced pipeline. However, women continue to face barriers in seeking leadership roles and achieving economic equity and scholarship recognition. In an effort to evaluate the status of women in dental research and academia, the authors examined the role of the International Association for Dental Research (IADR), a global research organization, which has improved awareness on gender inequality. The goal of this article is to review five crucial issues of gender inequality in oral health research and academics-workforce pipeline, economic inequality, workplace harassment, gender bias in scholarly productivity, and work-life balance-and to discuss proactive steps that the IADR has taken to promote gender equality. Providing networking and training opportunities through effective mentoring and coaching for women researchers, the IADR has developed a robust pipeline of women leaders while promoting gender equality for women in dental academia through a culture shift. As knowledge gaps remained on the levels of conscious and unconscious bias and sexist culture affecting women advancement in academics, as well as the intersectionality of gender with race, gender identity, ability status, sexual orientation, and cultural backgrounds, the IADR has recognized that further research is warranted.

Behavior Change for Caries Prevention: Understanding Inconsistent Results

Most applied work on caries prevention acknowledges the role of oral hygiene and dietary control strategies in reducing the prevalence and incidence of caries. What we seldom address, however, is the necessity of initiating and sustaining behaviors that will ensure these strategies are implemented. Virtually every approach to prevention of caries requires the individual to do something, that is, to engage in different behavior. We are continually confronted by the fact that to improve oral health, individuals must behave in new ways. Strategies for achieving better oral health most often have relied on providing information or telling people what they should or should not do. These approaches have not proven highly effective, yet they continue to be the mainstay of efforts to improve oral health. Acknowledging this failure, dental behavioral scientists have turned to the health beliefs model or to other cognitive-behavioral models, with their emphases on relative risks, barriers, and readiness to change. These models help us to conceptualize what people are doing to keep themselves, or their children, orally healthy, but the success of these models has been only marginal, especially among groups where disparities are extreme. In response, increasingly complex models that require attention to social and environmental variables, as well as individual behavior, have been proposed. Acknowledgment of “upstream variables” has become common—especially when working with populations experiencing health disparities, but overcoming upstream influences can appear to require sweeping changes that we often are not in a position to address. Consequently, research only picks away at individual elements of models, seeking the behavioral “magic bullet.” In an effort to elucidate the challenges, this article introduces the construct of overdetermination of behavior and encourages more rigorous documentation of potential determinants, as well as personalized development of behavioral approaches for implementing strategies to improve oral health.

KNOWLEDGE TRANSFER STATEMENT

This article reexamines our inconsistent results in effecting behavior change for better oral health using 2 important psychological constructs: "upstream variables" and the "overdetermination" of behavior.

Randomized Trial of Motivational Interviewing to Prevent Early Childhood Caries in American Indian Children

Introduction

In a randomized controlled trial, the effectiveness of motivational interviewing (MI) combined with enhanced community services (MI + ECS) was compared with ECS alone for reducing dental caries in American Indian children on the Pine Ridge Reservation. The intervention was developed and delivered with extensive tribal collaboration.

Methods

A total 579 mother-newborn dyads were enrolled and randomized to the MI + ECS and ECS groups. They were followed for 36 mo. Four MI sessions were provided, the first shortly after childbirth and then 6, 12, and 18 mo later. Both groups were exposed to ECS, which included public service announcements through billboards and tribal radio, as well as broad distribution of brochures on behavioral risk factors for early childhood caries (ECC), toothbrushes, and toothpaste. MI impact was measured as decayed, missing, and filled tooth surfaces (dmfs). Secondary outcomes included decayed surfaces, caries prevalence, and maternal oral health knowledge and behaviors. Modified intention-to-treat analyses were conducted. Eighty-eight percent of mothers completed at least 3 of 4 MI sessions offered.

Results

After 3 y, dmfs was not significantly different for the 2 groups (MI + ECS = 10, ECS = 10.38, P = 0.68). In both groups, prevalence of caries experience was 7% to 9% after 1 y, 35% to 36% at 2 y, and 55% to 56% at 3 y. Mean knowledge scores increased by 5.0, 5.3, and 5.9 percentage points at years 1, 2, and 3 in the MI + ECS group and by 1.9, 3.3, and 5.0 percentage points in the ECS group (P = 0.03), respectively. Mean maternal oral health behavior scores were not statistically significantly different between the treatment arms.

Conclusion

In summary, the MI intervention appeared to improve maternal knowledge but had no effect on oral health behaviors or on the progression of ECC (ClinicalTrials.gov NCT01116726).

Knowledge Transfer Statement

The findings of this study suggest that motivational interviewing focusing on parental behaviors may not be as effective as previously hoped for slowing the development of childhood caries in some high-risk groups. Furthermore, social factors may be even more salient determinants of oral health than what we previously supposed, perhaps interfering with the capacity to benefit from behavioral strategies that have been useful elsewhere. The improvement of children's oral health in high-risk populations characterized by poverty and multiple related life stresses may require more holistic approaches that address these formidable barriers.

Reducing Indigenous Oral Health Inequalities: A Review from 5 Nations

Indigenous populations around the world experience a disproportionate burden in terms of oral diseases and conditions. These inequalities are likely due to a complex web of social determinants that includes poverty, historical consequences of colonialism, social exclusion, government policies of assimilation, cultural annihilation, and racism in all its forms (societal, institutional). Despite documented oral health disparities, prevention interventions have been scarce in Indigenous communities. This review describes oral health interventions and their outcomes conducted for Indigenous populations of the United States, Canada, Brazil, Australia, and New Zealand. The review includes research published since 2006 that are available in English in electronic databases, including MEDLINE. A total of 13 studies were included from the United States, Canada, Brazil, and Australia. The studies reviewed provide a wide range of initiatives, including interventions for prevention and treatment of dental disease, as well as interventions that improve oral health knowledge, behaviors, and other psychosocial factors. Overall, 6 studies resulted in improved oral health in the study participants, including improvements in periodontal health, caries reduction, and oral health literacy. Preferred intervention methodologies included community-based research approaches, culturally tailored strategies, and use of community workers to deliver the initiative. Although these studies were conducted with discrete Indigenous populations, investigators reported similar challenges in research implementation. Recommendations for future work in reducing oral health disparities include addressing social determinants of health in various Indigenous populations, training future generations of dental providers in cultural competency, and making Indigenous communities true partners in research.

Preventing Caries in American Indian Children: Lost Battle or New Hope?

Knowledge Transfer Statement: Preventing early childhood caries in American Indian children has proved to be an unexpectedly challenging goal. Biological and behavioral variables, as well as parental psychosocial characteristics and experiences, suggest new routes for understanding and mitigating the progress of disease. We provide our reflections after a decade of studying these issues in collaboration with tribal communities.

Maternal Factors Associated with Early Childhood Caries in Urban Latino Children

The objective of this investigation was to describe maternal psychosocial, behavioral, and acculturation factors associated with early childhood caries in a sample of urban Latino mother-child dyads. A cross-sectional survey was conducted with 100 mothers whose children (under the age of 6 y) were patients at the Dental Center at Children's Hospital Colorado in Aurora, Colorado. All children participating in the study received an oral examination to measure decayed, missing, filled, surfaces (dmfs). Participating mothers were given the option to sign the consent form and complete the survey in English or Spanish, according to their preferred language. The survey used demographic, behavioral, knowledge, and several psychosocial variables. Bivariate analysis was conducted with dmfs as a dependent variable. The associations between independent variables and dmfs were modeled using negative binomial regression. Mean ± SD dmfs for the entire sample was about 11 ± 16.85. The mothers who spoke Spanish had children with significantly (P = 0.046) higher dmfs scores (15.2) compared to mothers who spoke English (7.56). Preference of Spanish language was significantly associated with self-efficacy (P = 0.0043), oral health knowledge (P = 0.0024), and 3 subscales of the health belief model: perceived severity (P = 0.057), perceived barriers (P = 0.0002), and perceived susceptibility (P = 0.008). Both in the univariate and the multivariate models, oral health behavior and preferential use of Spanish remained significantly associated with higher dmfs scores. Results of this study demonstrate that maternal oral health behaviors and preferred language are significant factors associated with early childhood caries in urban Latino children. Knowledge Transfer Statement: Results of this study indicate that maternal oral health behaviors and the level of acculturation are significantly associated with caries in urban Latino children. Caries prevention efforts in this population could use this information to tailor oral health messaging according to the level of acculturation in mothers.

A Cluster-Randomized, Community-Based, Tribally Delivered Oral Health Promotion Trial in Navajo Head Start Children

The authors tested the effectiveness of a community-based, tribally delivered oral health promotion (OHP) intervention (INT) at reducing caries increment in Navajo children attending Head Start. In a 3-y cluster-randomized trial, we developed an OHP INT with Navajo input that was delivered by trained Navajo lay health workers to children attending 52 Navajo Head Start classrooms (26 INT, 26 usual care [UC]). The INT was designed as a highly personalized set of oral health-focused interactions (5 for children and 4 for parents), along with 4 fluoride varnish applications delivered in Head Start during academic years of 2011 to 2012 and 2012 to 2013. The authors evaluated INT impact on decayed, missing, and filled tooth surfaces (dmfs) increment compared with UC. Other outcomes included caries prevalence and caregiver oral health-related knowledge and behaviors. Modified intention-to-treat and per-protocol analyses were conducted. The authors enrolled 1,016 caregiver-child dyads. Baseline mean dmfs/caries prevalence equaled 19.9/86.5% for the INT group and 22.8/90.1% for the UC group, respectively. INT adherence was 53% (i.e., ≥3 child OHP events, ≥1 caregiver OHP events, and ≥3 fluoride varnish). After 3 y, dmfs increased in both groups (+12.9 INT vs. +10.8 UC; P = 0.216), as did caries prevalence (86.5% to 96.6% INT vs. 90.1% to 98.2% UC; P = 0.808) in a modified intention-to-treat analysis of 897 caregiver-child dyads receiving 1 y of INT. Caregiver oral health knowledge scores improved in both groups (75.1% to 81.2% INT vs. 73.6% to 79.5% UC; P = 0.369). Caregiver oral health behavior scores improved more rapidly in the INT group versus the UC group (P = 0.006). The dmfs increment was smaller among adherent INT children (+8.9) than among UC children (+10.8; P = 0.028) in a per-protocol analysis. In conclusion, the severity of dental disease in Navajo Head Start children is extreme and difficult to improve. The authors argue that successful approaches to prevention may require even more highly personalized approaches shaped by cultural perspectives and attentive to the social determinants of oral health (ClinicalTrials.gov NCT01116739).

Preventing Childhood Caries: A Review of Recent Behavioral Research

The etiology of dental caries reflects a complex interplay of biochemical, microbial, genetic, social and physical environmental, and health-influencing behavioral factors. This review updates the literature on the efficacy of behavioral approaches to caries prevention for children up to 18 y of age. Included were studies of behavioral interventions implemented at individual, family, and community levels that assessed results in terms of reductions in caries increments. Only those reports published since 2011 were considered. Outcomes were variable, although motivational interviewing, which involves individuals in decisions about oral health within the context of their respective life circumstances, proved effective in 3 of 4 reported studies, and more definitive trials are underway. Recommendations for future research include examinations of the cost-effectiveness of interventions, as well as work focused on understanding the mechanisms underlying oral health behavior change and variables that may mediate or moderate responses to interventions.

Community Based Participatory Research to Reduce Oral Health Disparities in American Indian Children

Community based participatory research is an approach aimed to equitably involve community members, representatives, and academic researchers in all aspects of the research process. Using this methodology can help integrate cultural knowledge into interventions, supporting researchers to effectively partner with communities in addressing health disparities. The Center for Native Oral Health Research (CNOHR) collaborates with two American Indian (AI) tribes to advance oral health knowledge and practice, including the conduct of randomized controlled clinical trials of culturally sensitive behavioral interventions for primary prevention of early childhood caries (ECC). This manuscript describes the development of researcher-community partnership, and the development and implementation of the two clinical trial in the community. It also gives a detailed account of the strategies developed through the community input in recruitment and retention of the study participants and finally the lessons learnt during the study implementation.

Healthcare Worker Perceptions of Mask Use during a Nosocomial Pertussis Outbreak—Pennsylvania, 2003

BACKGROUND: Recent experiences with severe acute respiratory syndrome (SARS) and influenza have led to new Respiratory Hygiene and Cough Etiquette (RHCE) recommendations that include use of surgical masks by healthcare workers (HCWs) who come within 3 feet of all patients with symptoms of respiratory infection. In September 2003, prior to these recommendations, eight HCWs at a Pennsylvania tertiary-care hospital developed respiratory symptoms after exposure to an infant with pertussis. We observed that HCWs did not routinely wear masks while caring for patients with cough illness. Anticipating the new recommendations and in an effort to understand potential barriers for implementation, we evaluated perceptions of mask use among HCWs in this hospital.

METHODS: We conducted focus group discussions (FGDs) with two groups of nurses and one group of physicians (n1=4, n2=6, n3=9). Based on the discussions, we developed a structured, self-administered questionnaire for distribution to all HCWs present during two consecutive hospital shifts.

RESULTS: Overall, 96 of 120 (80%) HCWs responded. Forty-nine (51%) respondents viewed coughing patients as potentially contagious to other patients and HCWs, and 67 (70%) believed that they and their patients would be protected against droplet infections by masks. Forty-three (45%) HCWs perceived obstacles to using mask. Masks were considered a barrier to a trusting provider-patient relationship: 20 HCWs felt that a provider in a mask increased worries among patients, and 26 thought that the mask was a barrier to communicating with patients. Thirty respondents indicated that wearing a mask was uncomfortable and/or a burden. HCWs were less likely to perceive obstacles if they recognized a risk for patient-to-patient transmission (27/35 versus 31/61; P=0.0095).

CONCLUSIONS: Our findings suggest several potential barriers among HCWs to mask use, despite a recent pertussis outbreak in the hospital. HCWs may benefit from education regarding the risk of nosocomial transmission of respiratory pathogens such as SARS, influenza, and pertussis. Patients should be educated on the benefits of HCW mask use and its association with quality medical care.

Chloroquine for the treatment of uncomplicated malaria in Guyana

At a public hospital in Georgetown, Guyana, 44 patients seeking treatment for symptomatic, slide-confirmed malaria were given standard chloroquine (CQ) therapy and followed for 28 days. The patients apparently had pure infections with Plasmodium falciparum (14), P. vivax (13) or P. malariae (one), or mixed infections either of P. falciparum and P. vivax (17) or of P. falciparum, P. malariae and P. vivax (two). Each received supervised treatment with 10 mg CQ base/kg on each of days 0 and 1, and 5 mg/kg on day 2. On the day of enrollment (day 0), the patients complained of fever (100%), headache (100%), malaise (94%), myalgia (79%), nausea (67%), vertigo (49%) and vomiting (33%). Many (39%) were ill enough to confine themselves to bed. On day 4, fewer of the subjects complained of fever (15%), headache (15%), malaise (6%), myalgia (21%), nausea (6%), vertigo (24%) or vomiting (0%) despite the relatively high (>48%) risk of therapeutic failure. The cumulative incidence of parasitological failure against P. falciparum was 15% at day 4, 33% at day 7 and 48% at day 14. All of the P. vivax and P. malariae infections cleared before day 4 and none recurred by day 7. Two infections with P. vivax recurred later (on day 14 or 28) but in the presence of less than adequate, whole-blood concentrations of CQ plus desethyl-chloroquine (i.e. <100 ng/ml). Taken together, the results indicate a high risk of therapeutic failure of CQ against P. falciparum but also indicate that resistance to CQ in P. vivax occurs infrequently in Guyana.

American cutaneous leishmaniasis in Guyana, South America

The 185 patients who presented at the dermatology clinic of Georgetown Public Hospital, Guyana, between 1992 and 1998, with skin ulcers indicative of American cutaneous leishmaniasis (ACL) were retrospectively reviewed. The laboratory-confirmed cases of ACL were identified and the corresponding data were analysed for risk factors such as age, gender, areas of residence and of possible exposure to the causative agent (Leishmania braziliensis guyanensis), ethnic origin, longevity of the ulcers, and treatment regimes prior to the definitive diagnosis. Eighty-one (43%) of the 185 subjects were confirmed to be infected with Le. b. guyanensis. Although 53 (66%) of the cases lived in or close to the capital city, Georgetown, most of the cases had travelled to (and probably been infected in) region X in the interior of Guyana (32%) or regions VII (23%), VIII (23%), IX (11%), VI (5%), I (3%) or III (3%), usually because they were involved in the mining (41%) or lumber (21%) industries, the army or hunting. Almost all (95%) of the cases were male and most (58%) were aged 20-39 years. In general, the cases had had their skin lesions for many days before presenting for treatment: 46% for 1-5 weeks and 3% for > 6 months. Prior to presentation at the clinic, many of the cases had attempted to cure themselves, using local herbal remedies (37%), antibiotics and antifungal remedies (39%), other creams (5%), household chemicals (9%) or miscellaneous remedies such as lead salts (especially lead sulphate) and battery acid, all without success. Recommendations are made for an epidemiological study of active ACL among forest workers, eco-tourists and residents of high-risk areas. Diagnostic centres need to be sited in the regions most at-risk, particularly in or near environments in which the main vectors - sandflies such as Lutzomyia umbratilis, Lu. anduzei and Lu. whitmani - are known to be prevalent.

Lymphatic filariasis in the Caribbean region: the opportunity for its elimination and certification

In order to support the case for a certification of elimination of lymphatic filariasis (LF) in some Caribbean countries, we compared the prevalence of circulating Wuchereria bancrofti antigen in communities in Guyana, Suriname, and Trinidad. For the study, we assayed school children in six communities in Guyana, five communities in Suriname, and three communities in Trinidad for the prevalence of circulating W. bancrofti antigen, using a new immunochromatographic test for LF. We also assayed adults in these three countries, with a special focus on Blanchisseuse, Trinidad, where mass treatment for LF elimination had been carried out in 1981. The prevalences of W. bancrofti circulating antigen found in the school children populations ranged from 1.7% to 33.2% in Guyana and were 0.22% overall in Suriname and 0.0% in Trinidad. Among adults in two Guyana communities the prevalences were 16.7% and 32.1%. The results were all negative from 211 adults in communities in the north, center, and south of Trinidad, as well as from 29 adults in Suriname. The data suggest that contrary to reports of LF endemicity from the World Health Organization, LF may no longer be present in Trinidad and may be of very low prevalence in Suriname. Trinidad and Tobago and other Caribbean nations proven negative could seek to be awarded a certificate of LF elimination. In Suriname the small localized pocket of infected persons who may serve as a reservoir of LF infection could be tested and appropriately treated to achieve LF elimination. Such LF-positive countries as Guyana should access new international resources being made available for LF elimination efforts. An adequate certification program would help identify which countries should seek the new LF elimination resources.