Abstract
The Kona WIC oral health pilot project was developed to assess the oral health beliefs and behaviors of parents of children and pregnant women at the Kona WIC site and to demonstrate the ease of providing oral health education to families in order to improve oral health behaviors. Data were collected from 50 families about the oral health behaviors and dental care of a total of 73 children, including 5 pregnant women, four of whom had a child enrolled in WIC and one pregnant woman without any previous children. Data revealed that 68% of children with teeth had been seen by a dentist within 6 to 12 months of the study visit. Mothers were seen less often, with 55% stating that they had not been seen for a dental visit for over one year. Parental knowledge about the effects of fluoride on teeth was limited; however, 90% of the parents would allow fluoride varnish applied to their child's teeth, 88% would give daily fluoride drops/tablets to their child, and 78% would support water fluoridation if it would help to improve their children's oral health. Additionally, for children old enough to receive fluoride supplementation, 60% were not given a prescription by their health care providers, and 58% had not received any fluoride varnish applications. By offering oral health education in a WIC clinic and assisting clients to seek out comprehensive care within a dental home, children and caregivers can be provided essential education and resources early in a child's life or women's pregnancies to reduce poor oral health outcomes.
Keywords: WIC Clinics, Oral Health, Hawai‘i, Education
Introduction
The 2000 United States (US) Surgeon General's report on oral health highlighted the burden of oral diseases nationally, with particular attention paid to the pediatric population's vulnerability to dental decay. The report details the extent of this preventable infectious disease noting that dental caries is the most common chronic childhood disease, occurring 5 times more often than asthma1. Despite the existence of dental coverage, including Medicaid and the State Children's Health Insurance Program (SCHIP), children living in poverty continue to be less likely to access preventive dental services compared to their more affluent peers.2–4 According to a Pew Charitable Trust report,5 of the 29 million children enrolled in Medicaid nationally, only 12.9 million received dental care, with the major limiting factor being the inability to access a provider. Within the year 2014 alone, more than 18 million low-income children in the US did not receive any preventive or restorative dental care.4
Oral Health in Hawai‘i
Hawai‘i received a grade of “F” in three recent years from the Pew Center on the States,5 when compared to other US states based on key oral health measures. Recently, the Hawai‘i State Department of Health (HDOH) third grade oral health surveillance report revealed that more than 7 out of 10 third graders (71%) experienced tooth decay, with 22% of them having untreated decay.6 In addition, during 2011–2012, 29% of low-income children ages 1 to 17 years in Hawai‘i had dental problems 6 months prior to the time of data collection, compared to 13% of the higher-income children.7
Hawai‘i also faces several other challenges to accessing oral health services. Geographical challenges contribute to limited access to dental care particularly for those residents living on islands other than O‘ahu. Children living in Kaua‘i, Hawai‘i and Maui counties (all considered rural areas of the State) have been documented to have more tooth decay than children living in the largely urban Honolulu County, O‘ahu.6 The third-grade oral health surveillance report also identified oral health disparities in children based on their race/ethnic background, with Micronesian and other Pacific Islanders having the highest prevalence of untreated decay.6 Compounding the problem is the lack of a dental school in the State, which further reduces access to dental services; and the lack of community water fluoridation for the majority of the regions of the State, with only those living on military bases (ie, 11% of the State's population) receiving the benefits of water fluoridation.
There are equally disturbing oral health outcomes for Hawaii's adult population, particularly those from lower socioeconomic backgrounds. Starting in 2009, dental coverage for adults with Quest (ie, Medicaid) insurance was changed to only cover emergency dental care. This resulted in a further decline in the number of high-risk adults seeking preventive dental care, thereby, placing them at additional risk for developing dental decay and the adverse oral and systemic outcomes associated with periodontal disease. Moreover, reports from the Hawai‘i Pregnancy Risk Assessment Monitoring System (PRAMS) indicated that only 41% of pregnant women reported seeing a dentist during their pregnancy,8 although there is ample evidence in the literature noting the importance and safety of dental care during pregnancy to reduce associated perinatal complications.9,10
These reports have resulted in an urgent call for innovative strategies to improve access to preventive oral health care for children and pregnant women. These strategies include enhancing the oral health education of health care professionals, encouraging the participation of non-dental health care professionals in oral health education and preventive interventions, and expanding the roles of dental hygiene professionals.
WIC and Oral Health
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is well known for its conveniently located clinics in communities where families with young children and pregnant women receive health and nutritional services, education, and assistance accessing other health and social services.11,12 It is founded on a philosophy of health promotion education and activities, making it an ideal environment to include oral health education to reinforce good oral health habits in the home and assist families in successfully accessing dental care.
The introduction of oral health education into WIC clinics is not a new idea as it has been implemented in WIC clinics throughout the country.13–17 Positive outcomes have been associated with WIC clinics' integration of oral health education including changes in oral health beliefs and behaviors for children and their families, increased rates of accessing preventive dental services in the community, and a reduction in early childhood caries.12,13,18 Oral health services in WIC clinics can also help pregnant women overcome some of the common barriers to accessing dental care by increasing their awareness about the importance of oral health, providing information about dental insurance, and referring them to dentists who are comfortable treating pregnant women and young children.11
Kona WIC Oral Health Pilot Project
The oral health initiative for the Kona WIC site was developed as a pilot project and a first step in the development of a simple and efficient solution to the problem of increasing parent's/guardian's knowledge about the importance of oral health behaviors and care, thereby reducing dental disease and its associated complications in pregnant women, children, and families. The Kona WIC site provides services to approximately 600 to 700 clients (ie, pregnant women, children under five years of age) per month.
The key components of the oral health pilot project were based upon reports in the literature of previous US programs' success in utilizing WIC clinics for early oral health education and early entry into dental care for high-risk populations.12,13,18 Two faculty members at the University of Hawai‘i at Manoa Department of Nursing (UHM DON) developed and implemented the pilot project at the Kona WIC site, including the development of educational materials.
The Kona WIC site was chosen because of its experience in oral health education and existing dental health activities through the Keiki Dental Days program. The Keiki Dental Days program occurs monthly with dental providers from the West Hawai‘i Community Health Center performing oral health assessments, applying fluoride varnish, and most importantly enrolling children into their community dental clinic for future preventive, and if needed, restorative care. The Kona WIC oral health pilot project was developed to enhance these services to pregnant women and mothers of children enrolled in WIC so that ongoing oral health content could be part of the WIC staff's education when the Keiki Dental Days dental providers were not onsite at the WIC clinic (ie, the majority of WIC clinic days).
Project Goals
The UHM DON faculty identified goals for the pilot project were approved by the HDOH Family Health Services Division and WIC Services Branch prior to the pilot project's implementation. The goals included documenting: (1) current oral health education and materials; (2) oral health beliefs and behaviors of Kona WIC clients; and (3) identifying any existing barriers to dental care access for families seen at the Kona WIC site. The overarching aim was to create a WIC oral health education and dental referral model that was time efficient, sustainable, and culturally appropriate for the ethnically diverse group of women enrolled in the Kona WIC clinic.
Methods
Program materials were developed based on a review of the literature documenting the recommended education and practices for integrating oral health into WIC clinics, with approval obtained through the University of Hawai‘i (UH) Committee on Human Studies (CHS) and the HDOH Institutional Review Board. The project consisted of a total of six visits to the Kona WIC clinic. The targeted sample size for the pilot was 100 parents or guardians of children or pregnant women that currently attend the Kona WIC clinic. Data collection occurred over a total of 5 to 6 days of routine WIC clinic scheduling. The first visit was a meeting of the WIC clinic staff to: (1) complete an education plan for the staff about oral health needs of young children and pregnant women in Hawai‘i; (2) the project details including the educational materials; and (3) address the staff's questions and/or concerns. During the subsequent five visits, the nursing faculty enrolled WIC clinic clients into the study. Sixty WIC clinic clients were asked by one of the front staff members if they would be interested in participating in a study about oral health which included a short survey, education, and the provision of dental supplies to them and their family members at the completion of the education session. Clients interested in participating in the study were provided the informed consent form(s), and once consent was obtained, they completed the oral health questionnaire(s). Two questionnaires were available for completion based on whether the participant was a pregnant woman and/or mother/parent/guardian of a child. The questionnaires were developed based on the results of previously published studies that provided validity and reliability of the questions that were included in the questionnaire,19,20 as well as feedback obtained from several members from the Hawai‘i Department of Health and State and national dental experts. The questionnaires elicited information about the women's/children's demographics, oral health beliefs and behaviors, and access to dental care in the community. Racial and ethnicity classifications were obtained by self-report and respondents could select as many categories as they felt appropriate. Multiple responses to the questions about racial/ethnic identity were reported and included as non-white, such as “Other Pacific Islander and Hispanic” or “four or more” where applicable, with exception to Hawaiian for which all respondents self-identified as Native Hawaiian were included as Hawaiian. Upon completion of the questionnaire(s), oral health education was provided using the materials developed for children and pregnant women. Incentives for participating in the program included home dental care supplies for each family member. In addition, dental provider contact details were given to families who had not been seen by a dental provider in the past six months or had no identified dental provider.
Staff feedback about the project was obtained throughout the duration of the project. Based on staff concerns over the perceived time required to integrate oral health education into the WIC clinic visits and the sustainability of the project, the duration of the educational session was recorded for each client.
Descriptive analysis of clients' responses to questionnaire items was done using SPSS® version 23. Analysis was completed and frequencies for the responses to each of the questions within the oral health questionnaire were calculated based on the family's response as well as the responses for each individual child in the family.
Results
The project sample consisted of 50 parents/guardians that included 4 pregnant women who had a child currently enrolled in the WIC clinic for services as well as other children in the family, and one pregnant woman who was a primigravida. This resulted in data collection from 49 parents/guardians about the oral health care for 73 children. The information obtained included all children in the 49 parents/guardians whether or not they were currently enrolled in WIC. The children's ages ranged from 1 month to 14 years, with 16 (22%) identified by their parents as being 6 months of age or less; 11 (15%) were 7 to 12 months; 13 (18%) were 13–24 months of age; 21 (29%) were 25–60 months; with the remaining children (n=12, 16%) reported to be older than 60 months (data not shown). Due to the small number of pregnant women participating in the project, responses from the completed perinatal questionnaires were not included in this analysis.
Of the 49 parents/guardians who responded to the questionnaire, almost one-half (49%) were between the ages of 20–30 years, 37% were between 31–39 years, 10% were >39 years and 4% were noted to be < 20 years old (Table 1). More than a third (37%) of parents/guardians identified as being Native Hawaiian or Pacific Islander, followed by 31% Caucasian, 16% Filipino or Other Asian, 4% as American Indian or Native Alaskan, with 8% noting that they identified with four or more different cultural groups including Native Hawaiian. Also, almost a third (31%) noted that they were of Hispanic ethnicity. In addition, two thirds of the children (71%) were cared for by parents who had a high school or less than high school education.
Table 1.
Parent/Guardian Demographics (n=49)
| Frequency | Percent (%) | |
| Parent/Guardian Age | ||
| < 20 years | 2 | 4 |
| 20–30 years | 24 | 49 |
| 31–39 years | 18 | 37 |
| > 39 years | 5 | 10 |
| Current Relationship | ||
| Married | 26 | 54 |
| Divorced | 3 | 6 |
| Never married | 10 | 21 |
| Separated | 1 | 2 |
| Living with partner not married | 8 | 17 |
| Unknown | 1 | -- |
| Ethnicity | ||
| Hispanic, Latino | 15 | 31 |
| Non-Hispanic, Latino | 34 | 69 |
| Race | ||
| White | 15 | 31 |
| American Indian/Alaska Native | 2 | 4 |
| Native Hawaiian | 14 | 29 |
| Other | 2 | 4 |
| Filipino | 6 | 12 |
| Other Asian | 2 | 4 |
| Other Pacific Islander | 4 | 8 |
| Four or more | 4 | 8 |
| Highest level of education completed | ||
| Less than high school | 7 | 14 |
| High school | 28 | 57 |
| Associate degree or some college | 9 | 18 |
| Bachelor's degree | 5 | 10 |
Parents were then asked about the degree of importance of their child's baby teeth in comparison to their permanent (adult) teeth. Most respondents (96%) stated that their children's baby teeth were extremely important, while 4% stated they felt their child's baby teeth were moderately important compared to their adult teeth (data not shown). Parent's knowledge of fluoride was found to be limited with almost half (43%) stating that they had no knowledge about fluoride, while 41% stated that it was good for the teeth or strengthened the teeth (data not shown). Only a small number acknowledged having heard negative information about fluoride.
Three questions were included in the questionnaire to assess parents'/guardians' willingness to have their children receive fluoride supplement (Table 2). The parents'/guardians' responses to these questions indicate their willingness to provide fluoride supplements to their children based on the known benefits. Specifically, the majority of parents/guardians (90%) would allow their children to have fluoride varnish applications 2 to 3 times a year; 88% would give fluoride daily drops or tablets to their children; and 78% of the parents would support water fluoridation in Hawai‘i.
Table 2.
Parents' Willingness to Provide Fluoride Supplementation to the Family (n=49)
| Frequency | Percent | |
| Child fluoride drops and tablets could prevent half of your child's cavities. What would you think about giving your child fluoride drops or tablets every day until age 16? | ||
| Would definitely give it | 43 | 88 |
| Does not want to give it | 6 | 12 |
| Painting fluoride on your child's teeth 2–3 times a year could prevent half of your child's cavities. What do you think about having a dentist, dental hygienist, pediatrician or nurse practitioner painting fluoride on your child's teeth 2–3 times a year? | ||
| Would definitely allow it | 44 | 90 |
| Does not want it done | 5 | 10 |
| Adding a few drops of fluoride to the public drinking water would prevent half of your child's teeth cavities. What do you think about the State of Hawai‘i adding fluoride to the public drinking water? | ||
| Want it | 38 | 78 |
| Does not want it | 11 | 22 |
Despite the positive response to fluoride supplementation, not all parents were brushing their children's teeth with fluoride toothpaste, or they were not certain if the toothpaste they used contained fluoride. Additionally, for those children old enough to receive fluoride supplements (ie, >6 months of age), 60% were not given a fluoride prescription by their medical or dental provider, and 58% of the children had not received fluoride varnish (Table 3). Of those children old enough to receive preventive dental care, 68% were reported by their parents/guardians to have been seen by the dentist during the past 6 to 12 months, 5% had been seen 1 to 2 years previously, and 27% had never been seen for a dental assessment (data not shown). Conversely, mothers reported being seen less often, with over half (55%) without a dental visit for over one year, of which 25 % stated they has not been seen for over two years (data not shown).
Table 3.
Parent's Oral Health Beliefs and Behaviors for each Child (n=73)
| Frequency | Percent | |
| Do you use fluoride toothpaste to brush your child's teeth? | ||
| Yes, I use fluoride toothpaste | 35 | 70 |
| No, I use toothpaste without fluoride | 6 | 12 |
| No, I do not use toothpaste at all | 7 | 14 |
| I am not certain if the toothpaste has fluoride in it | 2 | 4 |
| N/A (has not cleaned teeth or child does not have teeth yet) | 23 | -- |
| Has your child's pediatrician prescribed fluoride drops or tablets for your child? | ||
| Yes | 25 | 40 |
| No | 38 | 60 |
| N/A < 6 months of age | 10 | -- |
| Has your child ever had fluoride varnish applied to their teeth? | ||
| Yes | 25 | 42 |
| No | 35 | 58 |
| N/A < 6 months of age or no teeth | 13 | -- |
Discussion
The results of this pilot project at the Kona WIC clinic provided previously undocumented information about an ethnically diverse group of clients' oral health knowledge, beliefs and behaviors. Information was obtained about the practices of dental and medical providers in terms of preventive interventions for children's oral health. In addition, the majority of participants reported a lack of parental/guardian knowledge about the benefits of fluoride for reducing caries risk in children. However, once the parents/guardians gained knowledge about the benefits of fluoride for their children, the vast majority wanted this option to be available to them. More than half of the parents/guardians reported that their children who were eligible for fluoride drops or tablets had not received a prescription from their children's dentist or pediatric health care provider. Similarly, participants reported that the majority (58%) of children eligible for fluoride varnish applications had not received these by their dentists and none of the children's primary pediatric health care providers had applied fluoride varnish to their children when they were seen. Therefore, it appears that there is a need to educate families and providers regarding the benefits of fluoride supplementation for children, based on current scientific evidence and national recommendations.
Despite having adequate Medicaid insurance coverage that provides preventive and restorative dental services, many children from low socioeconomic families in Hawai‘i continue to suffer from dental caries. Although socioeconomic status has been identified as a key social determinant of oral health, geographic location of residence can also impact dental access and outcomes. Families living in rural areas face several barriers when seeking dental care services for their children, including finding a dentist both able and willing to treat young children and willing to accept Medicaid reimbursement for dental services.21–25 Additional barriers include limited transportation, lack of oral health education of families, and family cultural views that may not support the importance of preventive dental services, thereby delaying the utilization of dental care services until tooth discomfort exists. 26 The WIC program is an ideal environment that can provide easy access to oral health education for children and families, especially and women prior to, during and after pregnancy. It embraces the shared goals of promoting good nutrition and feeding practices in the early stages of a child's life that contribute to both the oral and overall health of WIC clients.
To assure the Kona WIC clinic staff about the efficiency in delivering oral health education during WIC visits, the pilot project intervention was timed and found to take approximately 12 minutes to complete the entire visit, with the majority of time spent obtaining informed consent and completing the questionnaire. The average time to actually provide oral health education to the parents/guardians was five minutes, with some additional time required when clients had questions about oral health/dental care issues (eg, “When will dental care be covered by Quest?”). Therefore, the short time required to complete the oral health/dental care education of WIC clinic clients during this pilot project does not seem to be burdensome.
This pilot project's results were limited by the small sample size. In particular, the enrollment of only five pregnant women in the study did not allow for analysis about this population. Therefore, replicating the project at WIC sites with more pregnant clients than are enrolled at the Kona site could result in capturing important information about this vulnerable group. Additionally, a follow-up visit with pregnant women and/or parents/guardians who participated in the pilot project and completed the questionnaires and educational session was also not part of the project's approved plan. Therefore, there was no ability to assess the impact of the educational session on pregnant women's and/or parents'/guardians' changes in oral health beliefs and behaviors. Future projects such as this should include a follow-up assessment to determine the retention of knowledge, changes in oral hygiene behaviors, and how successful clients were at accessing dental services as a result of their oral health education through the WIC clinic.
Conclusion
The numerous effects of oral health disparities are far reaching for the children and families in Hawai‘i. Dental disease and the discomfort often associated with the most advanced forms of the disease can affect a child's ability to eat and drink, speech development, and their ability to learn in the classroom environment.1,27,28 Many women of childbearing age also suffer daily with pain and decreased quality of life associated with dental caries and periodontal disease. In addition, these women may suffer the ultimate cost of periodontal disease with the potential for poor pregnancy outcomes including preterm labor, preterm birth, low birth weight infants, and neonatal complications.
This project's simple and feasible approach to educating clients already enrolled in the WIC program can be effective in reducing the costs of dental care because of the decrease in the need for restorative procedures associated with early childhood caries. This brief educational intervention can improve the quality of life for children and other family members by providing consistent messages by WIC clinic staff reinforcing healthy habits that can reduce the rates of dental decay in children as well as in other family members.
A successful and sustainable WIC clinic-based oral health education program can be built upon a strong, trusting relationship between the state and/or local health departments, WIC clinics, community dental and health care providers, community stakeholders and professional organizations. By offering oral health education in a WIC clinic and assisting clients to seek out comprehensive care within a dental home, children and their caregivers can be provided education and resources early enough in a child's life or a women's pregnancy to reduce poor oral health outcomes.
Acknowledgments
This project could not have been successful without the funding provided by the Centers for Disease Control and Prevention through the State Oral Disease Prevention Program Cooperative Agreement (5U58DP004884) and collaboration with the Hawai‘i State Department of Health Family Health Services Division, Women, Infants, and Children (WIC) Services Branch Chief Linda Chock. We greatly appreciate the support provided by the Kona WIC staff before and during the project and their continued passion to improve oral health outcomes for the families in Kona, Hawai‘i, as well as the editorial assistance provided by Dr. Jennifer Domagalski DDS. The contents of this document are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or the Hawai‘i State Department of Health.
Conflict of Interest
None of the authors identify a conflict of interest.
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