Pediatric Residents’ Knowledge and Comfort With Oral Health Bright Futures Concepts: A CORNET Study Rani S. Gereige, MD, MPH, FAAP; Niramol Dhepyasuwan, MEd; Karla L. Garcia, MD; Rukmani Vasan, MD, MPH, MSEd; Janet R. Serwint, MD; Henry H. Bernstein, DO From the University of South Florida, Department of Pediatrics, Tampa, Fla (Dr Gereige); CORNET, Academic Pediatric Association, McLean, Va (Ms Dhepyasuwan); T. C. Thompson’s Children’s Hospital, Chattanooga, Tenn (Dr Garcia); University of Southern California, LACþUSC Medical Center, Los Angeles, Calif (Dr Vasan); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md (Dr Serwint); and Cohen Children’s Medical Center of New York, New Hyde Park, NY (Dr Bernstein) The authors declare that they have no conflict of interest. Address correspondence to Rani S. Gereige, MD, MPH, FAAP, Medical Education and DIO, Nicklaus Children’s Hospital, 3100 SW 62nd Ave, Miami, FL 33155 (e-mail: [email protected]). Received for publication October 23, 2014; accepted April 19, 2015.
ABSTRACT OBJECTIVE: Training residents in oral health helps eliminate disparities and improves access. The American Academy of Pediatrics Bright Futures Guidelines curriculum is used as a training guide. We assessed knowledge, confidence, and perceived barriers to incorporating Bright Futures oral health concepts into well-child care for children below 3 years in a national sample of pediatric residents. METHODS: A sample of postgraduate year 1 and 2 residents from CORNET sites completed demographic, Bright Futures oral health concepts confidence and knowledge crosssectional surveys before any intervention. Measures were tested for reliability using Cronbach’s alpha coefficient. RESULTS: One hundred sixty-three residents from 28 CORNET sites completed the surveys. One third reported no prior training in oral health. Time (42%) and knowledge (33%) led the perceived barriers to addressing these concepts in well visits. Although 63% rated their confidence as excellent in identifying tooth decay risk factors, a significant percentage
rated their oral health risk assessment skills as poor or neutral (64%) and identifying caries at examination (53%). Only 49% conveyed oral health messages during encounters and 80% correctly scored 75% or higher on knowledge questions. CONCLUSIONS: This cross-sectional study shows that residents from a wide geographic range have high self-reported oral health knowledge but low perceived skills and competency in clinical implementation. Lack of time and knowledge in identifying caries led the perceived barriers. Barriers are addressed by implementing oral health curricula that promote competence and skill-development. This study helps programs effectively implement Bright Futures concepts to train graduates to incorporate oral health in well visits.
KEYWORDS: Bright Futures; CORNET; knowledge; medical education; oral health; resident education ACADEMIC PEDIATRICS 2015;-:1–6
WHAT’S NEW
vulnerable children.2 The 2003 AAP policy statement “Oral Health Risk Assessment, Timing, and Establishment of the Dental Home” recommended the incorporation of oral health risk assessment, anticipatory guidance, and education into the well-child visit by 6 months of age. The pediatrician’s role in oral health was further formalized in 2008 through the publication of the AAP policy statement, “Preventive Oral Health Interventions for Pediatricians.”3 Despite progress in addressing oral health issues, disparities remain. Dental caries are the most common chronic disease of childhood, affecting 5 to 8 times as many children as asthma, including more than 50% of children by midchildhood and about 80% by late adolescence.4 Oral health disparities are multifactorial and are related to access to care as well as financial, cultural, and public health causes. In addition, failure to integrate oral health into pediatric training can lead directly to poorer health outcomes.4 A 2008 AAP periodic survey of fellows3 found
This cross-sectional assessment of a geographically diverse multi-institutional sample of residents adds a more detailed look at barriers to applying Bright Futures oral health concepts in continuity clinic. This helps educators design implementation strategies to supplement knowledge and confidence acquisition.
THE 2000 SURGEON General’s report on oral health in America highlighted the disparities in oral health and access to care for vulnerable populations, especially poor and underserved children, and called for action.1 The American Academy of Pediatrics (AAP), the American Academy of Family Physicians, and the Society of Teachers of Family Medicine have responded to this call by supporting training programs designed to increase physicians’ engagement in oral health, particularly for high-risk and ACADEMIC PEDIATRICS Copyright ª 2015 by Academic Pediatric Association
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that only 36% of respondents reported any previous training in oral health, with 13% receiving at least some training in medical school, 16% in residency, and 22% after residency. Those pediatricians without any formal training cited this as a barrier to providing oral health care to their patients younger than 3 years old. Many practicing pediatricians lack the scientific knowledge about transmissibility of caries, sealants, or fluoride varnishes.4 The AAP Bright Futures guidelines5 incorporated oral heath risk assessment, referral, and anticipatory guidance into its oral health curriculum. One pediatric-focused Bright Futures oral health curriculum has been documented to have a positive impact on resident knowledge and confidence.6 What this study adds to the previously published study is a more detailed assessment of the perceived barriers to the clinical application of oral health knowledge. Although a majority of pediatric training programs in the United States use the Bright Futures guidelines concepts as a guide for residents’ ambulatory and continuity clinic experiences, pediatric residents’ perceptions, knowledge, and barriers to implementation of its oral health elements are not known. Understanding these concepts is valuable to training programs and continuity clinic directors to design and implement strategies in the clinical setting to supplement learners’ knowledge and confidence acquisition. The main objective of this study is to assess the knowledge, confidence, and perceived barriers to incorporating Bright Futures oral health concepts and promotion into routine well-child care for children younger than 3 years in a national sample of pediatric residents.
PATIENTS AND METHODS STUDY POPULATION Sample.—Pediatric categorical residents were eligible if their continuity practice was enrolled in the Continuity Research Network (CORNET) and had agreed to participate in the study. CORNET is a national primary care practice-based research network of pediatric continuity
ACADEMIC PEDIATRICS
clinics endorsed as a core function of the Academic Pediatric Association. CORNET research goals include the study of health care issues of minority and low-income children, health disparities, and resident education. When study enrollment began in 2007, all 77 CORNET site champions enrolled at that time were sent an invitation to participate. Although 31 programs indicated initial interest, 26 programs completed the study. Figure 1 shows the geographic distribution of the participating sites compared to all CORNET sites. Enrollment.—Eligibility criteria included residents at postgraduate year 1 or 2 levels of training in order to assure study completion before their general pediatric training was finished. Recruitment of only a subset of all possible residents from each continuity practice was decided to minimize the local research burden; site champions selfdetermined the number of residents who would participate. Individual resident recruitment was at the discretion of site investigators. Recruitment methods were random and varied from residents’ voluntary self-selection, to including those residents in the study faculty’s continuity group for ease of implementation of the Bright Futures oral health curriculum. A range of 4 to 12 residents were recruited per site. The completion of the preintervention Web-based surveys, sent directly to participants as a link, took place from November 2007 to December 2009 and reflected the time frame before exposure to an oral health curriculum. STUDY IMPLEMENTATION The administration of the preintervention surveys was the first phase of a larger cluster randomized controlled trial to evaluate an oral health curriculum.6 We present here the results of the cross-sectional surveys completed by residents before involvement in the curriculum. Survey items included individual demographics, as well as their confidence and knowledge of Bright Futures concepts and pediatric oral health. Residents were emailed the 3 Web-based surveys by the site champion at their institution with follow-up reminders sent every other week up to 5 total reminders.
Figure 1. Map shows the location of the participating sites. Drop points indicate Bright Future Oral Health Project participating sites; drop points and dots, all CORNET sites.
ACADEMIC PEDIATRICS
ORAL HEALTH BRIGHT FUTURES CONCEPTS
Institutional review board approval was obtained at each CORNET site, and written informed consent was obtained from each resident. Each CORNET site received a small reimbursement to cover expenses related to study participation. STUDY INSTRUMENTS Demographics and perceived role survey.—This preintervention Web-based survey included 8 questions intended to collect baseline data on all participating residents, including age, sex, ethnicity, race, year of training, amount of exposure to Bright Futures and oral health concepts in medical school and residency so far, self-rated ability to implement Bright Futures and oral health concepts during primary care visits, and perceived barriers that impact the integration of specific health promotion elements into clinical practice (Online Appendix A). Confidence survey.—The Web-based confidence survey included 24 questions that assessed resident self-rated ability to understand, define meanings, articulate benefits, and implement various Bright Futures and oral health concepts. Responses to confidence questions were measured by selfreport with a 5-point Likert scale. Knowledge survey.—The Web-based knowledge survey included 38 multiple-choice Bright Futures and oral health questions adapted from Pediatrics in Practice: A Health Promotion Curriculum for Child Health Professionals7 and “Open Wide: Oral Training for Health Professionals,”8 respectively. STATISTICAL ANALYSIS All measures were tested for reliability using Cronbach’s alpha coefficient. Scale reliability for confidence items (a Bright Futures ¼ 0.871 and oral health ¼ 0.850) was good, but poor for knowledge items (a Bright Futures ¼ 0.137 and oral health ¼ 0.450). The knowledge item scales were retained even though they demonstrated low reliability because they made sense conceptually. The analyses included frequency calculations of the residents’ responses. Confidence survey responses on the 5-point Likert scale were combined with 1 and 2 as poor, 3 as neutral, and 4 and 5 as excellent. All analyses were performed by SPSS software version 18 (IBM, Armonk, NY).
RESULTS DEMOGRAPHICS One hundred sixty-three (73%) of the 224 residents initially enrolled onto the study from 28 CORNET continuity practices completed the survey. A mean of 6 residents per program (range, 4–12) participated. The majority of respondents were female (80%), white (76%), and postgraduate year 1 (45%) and 2 (51%). The Table highlights the characteristics of the residents who completed the survey. A majority (54%) of residents reported attending 1 or 2 lectures or training session in oral health, while one third reported no prior training (Fig. 2). Additionally, residents reported that they did not regularly address these concepts
3
Table. Characteristics of 163 Residents* Characteristic Sex Race
Year in residency
Variable
n (%)
Male White Asian Black/African American Other PL-1 PL-2 PL-3
33 (20) 119 (76) 24 (15) 8 (5) 6 (4) 73 (45) 83 (51) 7 (4)
*A mean of 6 residents were enrolled per program.
during patient visits in continuity clinic. Residents also indicated that oral health practice is a priority within the institution and their responsibility in the clinical setting. The most commonly perceived barriers to the integration of oral health promotion during well visits were time constraints (42%) and lack of knowledge (33%) (Fig. 3). CONFIDENCE Although almost 2 of 3 respondents (63%) rated their confidence as excellent in identifying risk factors for tooth decay, about two thirds (64%) rated their skills in conducting oral health risk assessment as poor or neutral, and more than half (53%) rated their skills in identifying dental caries at physical examination as poor or neutral (Fig. 4). KNOWLEDGE Most residents (80%) correctly scored 75% or higher on oral health knowledge questions. Although nearly all residents (98%) felt personal responsibility to promote oral health, only 49% reported conveying oral health messages during the majority of patient encounters.
DISCUSSION Our study is unique in that it involves a large number of pediatric residents from multiple geographic locations in the United States. We documented that although pediatric residents scored well on the oral health knowledge items, they reported poor confidence in identifying and assessing oral health risk factors, particularly when it came to their skills in identifying dental caries at physical examination and conducting the oral health risk assessments. This highlights the need to implement oral health didactic education in residency training with skill-building training sessions to
Figure 2. Residents’ prior training in oral health.
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Figure 3. Barriers perceived by residents that impact on integration of oral health promotion.
increase resident competency in performing the oral health risk assessment, including the oral examination. This might address the time constraint barrier as well, as residents become more proficient in their skills. One study noted an improvement in oral health knowledge and behaviors by pediatric residents through successful incorporation of infant oral health education during residency training.9 Another study similarly noted improved knowledge of oral health, confidence in providing oral health services, and delivery of those services by pediatric residents in their ambulatory care practices using a multifaceted instruction compared with a program that had a short practicum and another program with no specific oral health instructions.10 However, this study differs from ours in that it involved only 1 residency program as the intervention group with 2 comparison groups. When it comes to skill building, a study by Pierce and colleagues11 documented that practicing pediatric primary care providers can be trained to identify caries and make appropriate referrals, using as the reference standard a comparison of pediatric dentist’s examination of the same patients. Time constraints were the most common perceived barrier to implementation of oral health assessments into practice. Residents felt more confident about providing anticipatory guidance and education, yet they were less confident in identifying dental decay at examination and assessing oral health risk. This translates into barriers to implementation of the acquired knowledge in the clinical setting. Previous studies have not focused on barriers to
ACADEMIC PEDIATRICS
residents’ incorporation of oral health in well-child visits. However, our findings are consistent with another survey that assessed barriers perceived by practicing pediatricians.3 Pediatricians see it within their purview to educate families about preventive oral health and to assess patients for dental caries; however, relatively fewer respondents reported actually performing oral health–related activities. Our study participants reported a strong personal responsibility to promote oral health. This is consistent with prior national surveys of practicing physicians that looked at attitude toward their role in oral health.12,13 Educators must ensure that Bright Futures oral health concepts are included within training programs. In addition, they must engage their pediatric leadership to implement faculty development for the preceptors, and work with continuity clinic directors to establish work flow strategies to overcome the time constraint barrier. The AAP Bright Futures guidelines provide a standardized approach to incorporation of oral health risk assessment and anticipatory guidance into the well-child visit. The effectiveness of the content of the Bright Futures curriculum in improving residents’ competency in oral health examinations has been documented in an earlier study.6 However, training programs must focus on ways to facilitate the clinical implementation of the acquired knowledge and competency in order to overcome the perceived barriers related to time constraints and confidence levels in identifying caries at physical examination and identifying oral health risk. Residency programs must supplement the oral health education provided by the Bright Futures content with implementation strategies that address barriers and increase the level of comfort in incorporation of the learned knowledge in the well visit. Strategies that might be of value include the following: focusing on boosting the experience and comfort level of faculty preceptors (faculty development), addressing systems issues related to clinic flow, adopting time-efficient strategies for implementation, making use of technology through electronic health records templates, and/or exploring various ways to incorporate the oral health Bright Future elements into the well visit. This study confirms that conferring
Figure 4. Residents’ confidence in ability to identify and assess oral health factors (%).
ACADEMIC PEDIATRICS
knowledge does not necessarily translate into clinical application unless strategies address faculty development and work flow issues. Online Appendix B highlights an example of curricular interventions successfully implemented by one of the participating residency programs to address the perceived barriers. The national reach and distribution of respondents is a strength of this study. The sample of participating residents had 80% female subjects. This is representative of the sex distribution of the overall programs based on data from a random subset of the participating programs that showed 75% to be female at the time of the study. In addition, the American Medical Association Graduate Medical Education census reported that female pediatric residents make up to 73.2% of the total pediatric residents in programs as of December 2009. No data were captured on the ratio of international versus US graduates in the study sample. Uniquely, we are one of the few studies that explored the Bright Futures oral health concepts in trainees at multiple sites in multiple geographic locations throughout the United States. This provided us with a more generalizable perspective to the assessment of knowledge, comfort levels, skills, and perceived barriers. The study has limitations. The selection of residents at the discretion of the site investigators might be a source of potential bias, yet most enrolled residents in the site champion continuity group and did not strongly think that significant bias was introduced by their method because the enrollment method was random and because participation was voluntary and open to all eligible residents to self-select. There is reporting bias inherent to survey design because outcomes are by self-report. Another limitation includes the skewed distribution of respondents, with the majority (76%) being white; however, a random subset of participating programs surveyed showed an overall comparable ethnic makeup with 77.43% white in the program at the time of the study, making the sample more representative. The sample size was not large enough to allow stratification by training level, geographic location of the program, race, sex, number of sessions in the curriculum, or the program affiliation with dental school. Nevertheless, the information provided by the study is valuable in addressing issues related to practical implementation of learned knowledge, barriers, and competency. It also gave a global view of the knowledge level of respondents who are at multiple residency training programs.
CONCLUSIONS Our multicenter cross-sectional study shows that pediatric residents from training programs across a wide geographic range in the United States have high selfreported oral health knowledge but low perceived oral health skills and competency, particularly when it comes to clinical implementation. The study also helped identify the leading perceived barriers to the integration of oral health into well visits: time constraints and lack of knowledge in identifying dental caries on the well-
ORAL HEALTH BRIGHT FUTURES CONCEPTS
5
child examination. These data may be helpful in future designs of oral health curriculum and highlight the need to focus on skill development and the assessment of barriers to implementation in clinical practice settings. Early childhood caries remain a chronic disease that affects the dental and overall health of our youngest and most vulnerable children and that places a burden our society, with substantial dental, health care, and social costs.14 Early education and intervention are the keys to preventing caries.15 Pediatric residency programs must incorporate oral health into pediatric training beyond knowledge provision to achieve trainees’ competence and skill development. This will help graduates overcome the barriers to incorporating oral health as part of each well visit by providing early prevention strategies, providing anticipatory guidance, and ensuring that every child has a dental home.
ACKNOWLEDGMENTS This study was supported by grant 5R40MC05267 from the Health Resources and Services Administration Maternal and Child Health Bureau, with additional support from the Academic Pediatric Association and the Department of Pediatrics at Children’s Hospital at Dartmouth. These sponsors did not have any role in the study design, the collection, analysis, and interpretation of the data, the writing of the report, or the decision to submit the manuscript for publication. No honoraria, grants, or other forms of payment were given to anyone to produce the manuscript. We appreciate the notable efforts of each participating CORNET practice, especially their site coinvestigators and pediatric residents. Academic sites and site coinvestigators are: Baystate Medical Center, Mass—Patrick Brown and Cheryl Tierney; Brody School of Medicine at East Carolina University, NC—John Olsson and Kathleen Previll; Children’s Hospital of Austin, Tex—Marilyn Doyle, Michelle Gallas and Roberto Rodriguez; Children’s Memorial Hospital/Northwestern University, Ill—Sandy Sanguino and Bob Tanz; Children’s Mercy Hospitals & Clinics, Mo—Maria Dycoco and Nasreen Talib; Dartmouth Hitchcock Medical Center, NH— Diane Kittredge and Susanne Tanski; Fletcher Allen Healthcare/University of Vermont College of Medicine, Vt—Jerry Larrabee and Mort Wasserman; Helen Devos Children’s Hospital, Mich—Ben Sarver and Bill Stratbucker; Johns Hopkins University School of Medicine, Md—Mike Crocetti, Robert Dudas and Denisse Mueller; Medical University of South Carolina, SC—Kristina Gustafson; Metrohealth Medical Center, Ohio— Abdulla Gori and Susan Post; New York University, NY—Cynthia Cutler, Arthur Fierman, and Cindy Osman; Oregon Health & Science University, Ore—Cindy Ferrell, Arthur Jaffe, Marlo McIlraith, and Angeles Pena; St Christopher’s Hospital for Children, Pa—Robert Bonner and Shareen Kelly; St Louis University School of Medicine, Mo—Heidi Sallee and Sue Heaney; Stony Brook University Medical Center, NY—Robyn Blair and Susan Guralnick; T. C. Thompson’s Children’s Hospital, Tenn—Annamaria Church, Karla L Garcia, Joani Jack; University of Arkansas for Medical Sciences/Arkansas Children’s Hospital, Ark—Shelly Baldwin and Lanessa Bass; University of California, Irvine, Calif—Lynn Hunt, Penny Murata, and Vara Reddy; University of Connecticut. School of Medicine, Conn—Grael O’Brien; University of Florida, Fla—Don Fillipps and Lindsay Thompson; University of Maryland, Md—Susan Feigelman; University of Miami/Jackson Memorial Hospital, Fla—Andrea Assantes, Lourdes Forster, and Lee Sanders; University of Nebraska Medical Center, Neb—Sheilah Snyder; University of South Florida, Fla— Sharon Dabrow and Rani Gereige; University of Southern California, LAC þ USC Medical Center, Calif—Madeleine Bruning, Rukmani Vasan, and Jennifer Saenz; Wilmington Hospital Health Center, Del—Shirley Klein and Renee Kottenhahn.
SUPPLEMENTARY DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.acap.2015.04.036.
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REFERENCES 1. US Department of Health and Human Services; Public Health Service, Office of the Surgeon General. Oral Health in America: A Report of the Surgeon General. Rockville, Md: National Institutes of Health; National Institute of Dental and Craniofacial Research; 2000. 2. Douglass AB, Douglass JM, Krol DM. Educating pediatricians and family physicians in children’s oral health. Acad Pediatr. 2009;9: 452–456. 3. Lewis CW, Boulter S, Ann Keels M, et al. Oral health and pediatricians: results of a national survey. Acad Pediatr. 2009;9: 457–461. 4. Mouradian WE, Wehr E, Crall JJ. Disparities in children’s oral health and access to dental care. JAMA. 2000;284:2625–2631. 5. Hagan JF, Shaw JS, Duncan P. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2008. 6. Bernstein HH, Dhepayasuwan N, Connors K, et al. Evaluation of a national Bright Futures oral health curriculum for pediatric residents. Acad Pediatr. 2013;13:133–139. 7. Bernstein HH. Pediatrics in Practice: A Health Promotion Curriculum for Child Health Professionals. New York, NY: Springer; 2005.
ACADEMIC PEDIATRICS 8. Holt K, Barzel R. Open wide: oral health training for health professionals. Available at: http://www.mchoralhealth.org/openwide. Accessed July 30, 2011. 9. Douglass JM, Douglass AB, Silk HJ. Infant oral health education for pediatric and family practice residents. Pediatr Dent. 2005;27: 284–291. 10. Blass ES, Rozier RG, Chattopadhyay A, et al. Effectiveness of an educational intervention in oral health for pediatric residents. Ambul Pediatr. 2006;6:157–164. 11. Pierce KM, Rozier RG, Vann WF Jr. Accuracy of pediatric primary care providers’ screening and referral for early childhood caries. Pediatrics. 2002;109:E82. 12. Lewis CW, Grossman DC, Domoto PK, et al. The role of the pediatrician in the oral health of children: a national survey. Pediatrics. 2000; 106:E84. 13. Ismail AI, Nainar SM, Sohn W. Children’s first dental visit: attitudes and practices of US pediatricians and family physicians. Pediatr Dent. 2003;25:425–430. 14. American Academy of Pediatric Dentristry. State of Little Teeth: Dangers of Tooth Decay to Young Children. Available at: http:// www.aapd.org/assets/1/7/State_of_Little_Teeth_Final.pdf; 2013. Accessed April 21, 2015. 15. National Poverty Center. Poverty in the United States. Available at: http://www.npc.umich.edu/poverty/. Accessed April 21, 2015.
ABSTRACT OBJECTIVE: Training residents in oral health helps eliminate disparities and improves access. The American Academy of Pediatrics Bright Futures Guidelines curriculum is used as a training guide. We assessed knowledge, confidence, and perceived barriers to incorporating Bright Futures oral health concepts into well-child care for children below 3 years in a national sample of pediatric residents. METHODS: A sample of postgraduate year 1 and 2 residents from CORNET sites completed demographic, Bright Futures oral health concepts confidence and knowledge crosssectional surveys before any intervention. Measures were tested for reliability using Cronbach’s alpha coefficient. RESULTS: One hundred sixty-three residents from 28 CORNET sites completed the surveys. One third reported no prior training in oral health. Time (42%) and knowledge (33%) led the perceived barriers to addressing these concepts in well visits. Although 63% rated their confidence as excellent in identifying tooth decay risk factors, a significant percentage
rated their oral health risk assessment skills as poor or neutral (64%) and identifying caries at examination (53%). Only 49% conveyed oral health messages during encounters and 80% correctly scored 75% or higher on knowledge questions. CONCLUSIONS: This cross-sectional study shows that residents from a wide geographic range have high self-reported oral health knowledge but low perceived skills and competency in clinical implementation. Lack of time and knowledge in identifying caries led the perceived barriers. Barriers are addressed by implementing oral health curricula that promote competence and skill-development. This study helps programs effectively implement Bright Futures concepts to train graduates to incorporate oral health in well visits.
KEYWORDS: Bright Futures; CORNET; knowledge; medical education; oral health; resident education ACADEMIC PEDIATRICS 2015;-:1–6
WHAT’S NEW
vulnerable children.2 The 2003 AAP policy statement “Oral Health Risk Assessment, Timing, and Establishment of the Dental Home” recommended the incorporation of oral health risk assessment, anticipatory guidance, and education into the well-child visit by 6 months of age. The pediatrician’s role in oral health was further formalized in 2008 through the publication of the AAP policy statement, “Preventive Oral Health Interventions for Pediatricians.”3 Despite progress in addressing oral health issues, disparities remain. Dental caries are the most common chronic disease of childhood, affecting 5 to 8 times as many children as asthma, including more than 50% of children by midchildhood and about 80% by late adolescence.4 Oral health disparities are multifactorial and are related to access to care as well as financial, cultural, and public health causes. In addition, failure to integrate oral health into pediatric training can lead directly to poorer health outcomes.4 A 2008 AAP periodic survey of fellows3 found
This cross-sectional assessment of a geographically diverse multi-institutional sample of residents adds a more detailed look at barriers to applying Bright Futures oral health concepts in continuity clinic. This helps educators design implementation strategies to supplement knowledge and confidence acquisition.
THE 2000 SURGEON General’s report on oral health in America highlighted the disparities in oral health and access to care for vulnerable populations, especially poor and underserved children, and called for action.1 The American Academy of Pediatrics (AAP), the American Academy of Family Physicians, and the Society of Teachers of Family Medicine have responded to this call by supporting training programs designed to increase physicians’ engagement in oral health, particularly for high-risk and ACADEMIC PEDIATRICS Copyright ª 2015 by Academic Pediatric Association
1
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that only 36% of respondents reported any previous training in oral health, with 13% receiving at least some training in medical school, 16% in residency, and 22% after residency. Those pediatricians without any formal training cited this as a barrier to providing oral health care to their patients younger than 3 years old. Many practicing pediatricians lack the scientific knowledge about transmissibility of caries, sealants, or fluoride varnishes.4 The AAP Bright Futures guidelines5 incorporated oral heath risk assessment, referral, and anticipatory guidance into its oral health curriculum. One pediatric-focused Bright Futures oral health curriculum has been documented to have a positive impact on resident knowledge and confidence.6 What this study adds to the previously published study is a more detailed assessment of the perceived barriers to the clinical application of oral health knowledge. Although a majority of pediatric training programs in the United States use the Bright Futures guidelines concepts as a guide for residents’ ambulatory and continuity clinic experiences, pediatric residents’ perceptions, knowledge, and barriers to implementation of its oral health elements are not known. Understanding these concepts is valuable to training programs and continuity clinic directors to design and implement strategies in the clinical setting to supplement learners’ knowledge and confidence acquisition. The main objective of this study is to assess the knowledge, confidence, and perceived barriers to incorporating Bright Futures oral health concepts and promotion into routine well-child care for children younger than 3 years in a national sample of pediatric residents.
PATIENTS AND METHODS STUDY POPULATION Sample.—Pediatric categorical residents were eligible if their continuity practice was enrolled in the Continuity Research Network (CORNET) and had agreed to participate in the study. CORNET is a national primary care practice-based research network of pediatric continuity
ACADEMIC PEDIATRICS
clinics endorsed as a core function of the Academic Pediatric Association. CORNET research goals include the study of health care issues of minority and low-income children, health disparities, and resident education. When study enrollment began in 2007, all 77 CORNET site champions enrolled at that time were sent an invitation to participate. Although 31 programs indicated initial interest, 26 programs completed the study. Figure 1 shows the geographic distribution of the participating sites compared to all CORNET sites. Enrollment.—Eligibility criteria included residents at postgraduate year 1 or 2 levels of training in order to assure study completion before their general pediatric training was finished. Recruitment of only a subset of all possible residents from each continuity practice was decided to minimize the local research burden; site champions selfdetermined the number of residents who would participate. Individual resident recruitment was at the discretion of site investigators. Recruitment methods were random and varied from residents’ voluntary self-selection, to including those residents in the study faculty’s continuity group for ease of implementation of the Bright Futures oral health curriculum. A range of 4 to 12 residents were recruited per site. The completion of the preintervention Web-based surveys, sent directly to participants as a link, took place from November 2007 to December 2009 and reflected the time frame before exposure to an oral health curriculum. STUDY IMPLEMENTATION The administration of the preintervention surveys was the first phase of a larger cluster randomized controlled trial to evaluate an oral health curriculum.6 We present here the results of the cross-sectional surveys completed by residents before involvement in the curriculum. Survey items included individual demographics, as well as their confidence and knowledge of Bright Futures concepts and pediatric oral health. Residents were emailed the 3 Web-based surveys by the site champion at their institution with follow-up reminders sent every other week up to 5 total reminders.
Figure 1. Map shows the location of the participating sites. Drop points indicate Bright Future Oral Health Project participating sites; drop points and dots, all CORNET sites.
ACADEMIC PEDIATRICS
ORAL HEALTH BRIGHT FUTURES CONCEPTS
Institutional review board approval was obtained at each CORNET site, and written informed consent was obtained from each resident. Each CORNET site received a small reimbursement to cover expenses related to study participation. STUDY INSTRUMENTS Demographics and perceived role survey.—This preintervention Web-based survey included 8 questions intended to collect baseline data on all participating residents, including age, sex, ethnicity, race, year of training, amount of exposure to Bright Futures and oral health concepts in medical school and residency so far, self-rated ability to implement Bright Futures and oral health concepts during primary care visits, and perceived barriers that impact the integration of specific health promotion elements into clinical practice (Online Appendix A). Confidence survey.—The Web-based confidence survey included 24 questions that assessed resident self-rated ability to understand, define meanings, articulate benefits, and implement various Bright Futures and oral health concepts. Responses to confidence questions were measured by selfreport with a 5-point Likert scale. Knowledge survey.—The Web-based knowledge survey included 38 multiple-choice Bright Futures and oral health questions adapted from Pediatrics in Practice: A Health Promotion Curriculum for Child Health Professionals7 and “Open Wide: Oral Training for Health Professionals,”8 respectively. STATISTICAL ANALYSIS All measures were tested for reliability using Cronbach’s alpha coefficient. Scale reliability for confidence items (a Bright Futures ¼ 0.871 and oral health ¼ 0.850) was good, but poor for knowledge items (a Bright Futures ¼ 0.137 and oral health ¼ 0.450). The knowledge item scales were retained even though they demonstrated low reliability because they made sense conceptually. The analyses included frequency calculations of the residents’ responses. Confidence survey responses on the 5-point Likert scale were combined with 1 and 2 as poor, 3 as neutral, and 4 and 5 as excellent. All analyses were performed by SPSS software version 18 (IBM, Armonk, NY).
RESULTS DEMOGRAPHICS One hundred sixty-three (73%) of the 224 residents initially enrolled onto the study from 28 CORNET continuity practices completed the survey. A mean of 6 residents per program (range, 4–12) participated. The majority of respondents were female (80%), white (76%), and postgraduate year 1 (45%) and 2 (51%). The Table highlights the characteristics of the residents who completed the survey. A majority (54%) of residents reported attending 1 or 2 lectures or training session in oral health, while one third reported no prior training (Fig. 2). Additionally, residents reported that they did not regularly address these concepts
3
Table. Characteristics of 163 Residents* Characteristic Sex Race
Year in residency
Variable
n (%)
Male White Asian Black/African American Other PL-1 PL-2 PL-3
33 (20) 119 (76) 24 (15) 8 (5) 6 (4) 73 (45) 83 (51) 7 (4)
*A mean of 6 residents were enrolled per program.
during patient visits in continuity clinic. Residents also indicated that oral health practice is a priority within the institution and their responsibility in the clinical setting. The most commonly perceived barriers to the integration of oral health promotion during well visits were time constraints (42%) and lack of knowledge (33%) (Fig. 3). CONFIDENCE Although almost 2 of 3 respondents (63%) rated their confidence as excellent in identifying risk factors for tooth decay, about two thirds (64%) rated their skills in conducting oral health risk assessment as poor or neutral, and more than half (53%) rated their skills in identifying dental caries at physical examination as poor or neutral (Fig. 4). KNOWLEDGE Most residents (80%) correctly scored 75% or higher on oral health knowledge questions. Although nearly all residents (98%) felt personal responsibility to promote oral health, only 49% reported conveying oral health messages during the majority of patient encounters.
DISCUSSION Our study is unique in that it involves a large number of pediatric residents from multiple geographic locations in the United States. We documented that although pediatric residents scored well on the oral health knowledge items, they reported poor confidence in identifying and assessing oral health risk factors, particularly when it came to their skills in identifying dental caries at physical examination and conducting the oral health risk assessments. This highlights the need to implement oral health didactic education in residency training with skill-building training sessions to
Figure 2. Residents’ prior training in oral health.
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Figure 3. Barriers perceived by residents that impact on integration of oral health promotion.
increase resident competency in performing the oral health risk assessment, including the oral examination. This might address the time constraint barrier as well, as residents become more proficient in their skills. One study noted an improvement in oral health knowledge and behaviors by pediatric residents through successful incorporation of infant oral health education during residency training.9 Another study similarly noted improved knowledge of oral health, confidence in providing oral health services, and delivery of those services by pediatric residents in their ambulatory care practices using a multifaceted instruction compared with a program that had a short practicum and another program with no specific oral health instructions.10 However, this study differs from ours in that it involved only 1 residency program as the intervention group with 2 comparison groups. When it comes to skill building, a study by Pierce and colleagues11 documented that practicing pediatric primary care providers can be trained to identify caries and make appropriate referrals, using as the reference standard a comparison of pediatric dentist’s examination of the same patients. Time constraints were the most common perceived barrier to implementation of oral health assessments into practice. Residents felt more confident about providing anticipatory guidance and education, yet they were less confident in identifying dental decay at examination and assessing oral health risk. This translates into barriers to implementation of the acquired knowledge in the clinical setting. Previous studies have not focused on barriers to
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residents’ incorporation of oral health in well-child visits. However, our findings are consistent with another survey that assessed barriers perceived by practicing pediatricians.3 Pediatricians see it within their purview to educate families about preventive oral health and to assess patients for dental caries; however, relatively fewer respondents reported actually performing oral health–related activities. Our study participants reported a strong personal responsibility to promote oral health. This is consistent with prior national surveys of practicing physicians that looked at attitude toward their role in oral health.12,13 Educators must ensure that Bright Futures oral health concepts are included within training programs. In addition, they must engage their pediatric leadership to implement faculty development for the preceptors, and work with continuity clinic directors to establish work flow strategies to overcome the time constraint barrier. The AAP Bright Futures guidelines provide a standardized approach to incorporation of oral health risk assessment and anticipatory guidance into the well-child visit. The effectiveness of the content of the Bright Futures curriculum in improving residents’ competency in oral health examinations has been documented in an earlier study.6 However, training programs must focus on ways to facilitate the clinical implementation of the acquired knowledge and competency in order to overcome the perceived barriers related to time constraints and confidence levels in identifying caries at physical examination and identifying oral health risk. Residency programs must supplement the oral health education provided by the Bright Futures content with implementation strategies that address barriers and increase the level of comfort in incorporation of the learned knowledge in the well visit. Strategies that might be of value include the following: focusing on boosting the experience and comfort level of faculty preceptors (faculty development), addressing systems issues related to clinic flow, adopting time-efficient strategies for implementation, making use of technology through electronic health records templates, and/or exploring various ways to incorporate the oral health Bright Future elements into the well visit. This study confirms that conferring
Figure 4. Residents’ confidence in ability to identify and assess oral health factors (%).
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knowledge does not necessarily translate into clinical application unless strategies address faculty development and work flow issues. Online Appendix B highlights an example of curricular interventions successfully implemented by one of the participating residency programs to address the perceived barriers. The national reach and distribution of respondents is a strength of this study. The sample of participating residents had 80% female subjects. This is representative of the sex distribution of the overall programs based on data from a random subset of the participating programs that showed 75% to be female at the time of the study. In addition, the American Medical Association Graduate Medical Education census reported that female pediatric residents make up to 73.2% of the total pediatric residents in programs as of December 2009. No data were captured on the ratio of international versus US graduates in the study sample. Uniquely, we are one of the few studies that explored the Bright Futures oral health concepts in trainees at multiple sites in multiple geographic locations throughout the United States. This provided us with a more generalizable perspective to the assessment of knowledge, comfort levels, skills, and perceived barriers. The study has limitations. The selection of residents at the discretion of the site investigators might be a source of potential bias, yet most enrolled residents in the site champion continuity group and did not strongly think that significant bias was introduced by their method because the enrollment method was random and because participation was voluntary and open to all eligible residents to self-select. There is reporting bias inherent to survey design because outcomes are by self-report. Another limitation includes the skewed distribution of respondents, with the majority (76%) being white; however, a random subset of participating programs surveyed showed an overall comparable ethnic makeup with 77.43% white in the program at the time of the study, making the sample more representative. The sample size was not large enough to allow stratification by training level, geographic location of the program, race, sex, number of sessions in the curriculum, or the program affiliation with dental school. Nevertheless, the information provided by the study is valuable in addressing issues related to practical implementation of learned knowledge, barriers, and competency. It also gave a global view of the knowledge level of respondents who are at multiple residency training programs.
CONCLUSIONS Our multicenter cross-sectional study shows that pediatric residents from training programs across a wide geographic range in the United States have high selfreported oral health knowledge but low perceived oral health skills and competency, particularly when it comes to clinical implementation. The study also helped identify the leading perceived barriers to the integration of oral health into well visits: time constraints and lack of knowledge in identifying dental caries on the well-
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child examination. These data may be helpful in future designs of oral health curriculum and highlight the need to focus on skill development and the assessment of barriers to implementation in clinical practice settings. Early childhood caries remain a chronic disease that affects the dental and overall health of our youngest and most vulnerable children and that places a burden our society, with substantial dental, health care, and social costs.14 Early education and intervention are the keys to preventing caries.15 Pediatric residency programs must incorporate oral health into pediatric training beyond knowledge provision to achieve trainees’ competence and skill development. This will help graduates overcome the barriers to incorporating oral health as part of each well visit by providing early prevention strategies, providing anticipatory guidance, and ensuring that every child has a dental home.
ACKNOWLEDGMENTS This study was supported by grant 5R40MC05267 from the Health Resources and Services Administration Maternal and Child Health Bureau, with additional support from the Academic Pediatric Association and the Department of Pediatrics at Children’s Hospital at Dartmouth. These sponsors did not have any role in the study design, the collection, analysis, and interpretation of the data, the writing of the report, or the decision to submit the manuscript for publication. No honoraria, grants, or other forms of payment were given to anyone to produce the manuscript. We appreciate the notable efforts of each participating CORNET practice, especially their site coinvestigators and pediatric residents. Academic sites and site coinvestigators are: Baystate Medical Center, Mass—Patrick Brown and Cheryl Tierney; Brody School of Medicine at East Carolina University, NC—John Olsson and Kathleen Previll; Children’s Hospital of Austin, Tex—Marilyn Doyle, Michelle Gallas and Roberto Rodriguez; Children’s Memorial Hospital/Northwestern University, Ill—Sandy Sanguino and Bob Tanz; Children’s Mercy Hospitals & Clinics, Mo—Maria Dycoco and Nasreen Talib; Dartmouth Hitchcock Medical Center, NH— Diane Kittredge and Susanne Tanski; Fletcher Allen Healthcare/University of Vermont College of Medicine, Vt—Jerry Larrabee and Mort Wasserman; Helen Devos Children’s Hospital, Mich—Ben Sarver and Bill Stratbucker; Johns Hopkins University School of Medicine, Md—Mike Crocetti, Robert Dudas and Denisse Mueller; Medical University of South Carolina, SC—Kristina Gustafson; Metrohealth Medical Center, Ohio— Abdulla Gori and Susan Post; New York University, NY—Cynthia Cutler, Arthur Fierman, and Cindy Osman; Oregon Health & Science University, Ore—Cindy Ferrell, Arthur Jaffe, Marlo McIlraith, and Angeles Pena; St Christopher’s Hospital for Children, Pa—Robert Bonner and Shareen Kelly; St Louis University School of Medicine, Mo—Heidi Sallee and Sue Heaney; Stony Brook University Medical Center, NY—Robyn Blair and Susan Guralnick; T. C. Thompson’s Children’s Hospital, Tenn—Annamaria Church, Karla L Garcia, Joani Jack; University of Arkansas for Medical Sciences/Arkansas Children’s Hospital, Ark—Shelly Baldwin and Lanessa Bass; University of California, Irvine, Calif—Lynn Hunt, Penny Murata, and Vara Reddy; University of Connecticut. School of Medicine, Conn—Grael O’Brien; University of Florida, Fla—Don Fillipps and Lindsay Thompson; University of Maryland, Md—Susan Feigelman; University of Miami/Jackson Memorial Hospital, Fla—Andrea Assantes, Lourdes Forster, and Lee Sanders; University of Nebraska Medical Center, Neb—Sheilah Snyder; University of South Florida, Fla— Sharon Dabrow and Rani Gereige; University of Southern California, LAC þ USC Medical Center, Calif—Madeleine Bruning, Rukmani Vasan, and Jennifer Saenz; Wilmington Hospital Health Center, Del—Shirley Klein and Renee Kottenhahn.
SUPPLEMENTARY DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.acap.2015.04.036.
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REFERENCES 1. US Department of Health and Human Services; Public Health Service, Office of the Surgeon General. Oral Health in America: A Report of the Surgeon General. Rockville, Md: National Institutes of Health; National Institute of Dental and Craniofacial Research; 2000. 2. Douglass AB, Douglass JM, Krol DM. Educating pediatricians and family physicians in children’s oral health. Acad Pediatr. 2009;9: 452–456. 3. Lewis CW, Boulter S, Ann Keels M, et al. Oral health and pediatricians: results of a national survey. Acad Pediatr. 2009;9: 457–461. 4. Mouradian WE, Wehr E, Crall JJ. Disparities in children’s oral health and access to dental care. JAMA. 2000;284:2625–2631. 5. Hagan JF, Shaw JS, Duncan P. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2008. 6. Bernstein HH, Dhepayasuwan N, Connors K, et al. Evaluation of a national Bright Futures oral health curriculum for pediatric residents. Acad Pediatr. 2013;13:133–139. 7. Bernstein HH. Pediatrics in Practice: A Health Promotion Curriculum for Child Health Professionals. New York, NY: Springer; 2005.
ACADEMIC PEDIATRICS 8. Holt K, Barzel R. Open wide: oral health training for health professionals. Available at: http://www.mchoralhealth.org/openwide. Accessed July 30, 2011. 9. Douglass JM, Douglass AB, Silk HJ. Infant oral health education for pediatric and family practice residents. Pediatr Dent. 2005;27: 284–291. 10. Blass ES, Rozier RG, Chattopadhyay A, et al. Effectiveness of an educational intervention in oral health for pediatric residents. Ambul Pediatr. 2006;6:157–164. 11. Pierce KM, Rozier RG, Vann WF Jr. Accuracy of pediatric primary care providers’ screening and referral for early childhood caries. Pediatrics. 2002;109:E82. 12. Lewis CW, Grossman DC, Domoto PK, et al. The role of the pediatrician in the oral health of children: a national survey. Pediatrics. 2000; 106:E84. 13. Ismail AI, Nainar SM, Sohn W. Children’s first dental visit: attitudes and practices of US pediatricians and family physicians. Pediatr Dent. 2003;25:425–430. 14. American Academy of Pediatric Dentristry. State of Little Teeth: Dangers of Tooth Decay to Young Children. Available at: http:// www.aapd.org/assets/1/7/State_of_Little_Teeth_Final.pdf; 2013. Accessed April 21, 2015. 15. National Poverty Center. Poverty in the United States. Available at: http://www.npc.umich.edu/poverty/. Accessed April 21, 2015.
