Overview of Presentations
| "Challenges for Oral Health Promotion Research" |
| Dr. Kathryn Atchison |
| School of Dentistry |
| University of California at Los Angeles |
| Los Angeles, California |
Dentistry has been lauded for its emphasis on prevention and health promotion. As an example,
even before understanding the etiology of caries, dentists began preventive efforts with health education
and a regulatory process to establish community water fluoridation. Despite this, oral diseases continue to
threaten health and function--in some cases, such as oral cancers, even threaten lives. Also, serious
gaps persist between scientists' understanding of optimal preventive measures and providers' interest
in integrating improved preventive measures (e.g., dental sealants) into routine dental care.
Multifaceted preventive/health promotion efforts could do much to improve both oral and systemic health.
Such efforts would likely need to involve a combination of individual, community, professional, health policy,
and/or legal interventions. The type of health promotion intervention selected should arise from knowing
risk factors for the disease, and selecting both the professionals best positioned to provide education and
the interventions most likely to be successful. Improved science transfer mechanisms are needed so
that health professionals understand and utilize the most effective measures for preventing oral
diseases and so that the public also engages in behaviors supporting health and prevention of disease.
Information was presented about major oral diseases in order to to facilitate the groups' discussions
on risk profiles and health promotion interventions. Dr. Atchison noted that all oral diseases are
either infectious, acquired, or inherited/genetic in origin and that many oral diseases involve
multiple risks -- biological, behavioral, and environmental.
"Models for Health Promotion Research"
Dr. Lawrence Green
University of British Columbia
Vancouver, British Columbia
CANADA |
Most health resources in Canada and the U.S. (over 90 percent of all government expenditures on health)
are spent on medical care. Yet only 12 percent of preventable premature life loss can be attributed
to lack of medical care services. Less than 10 percent of government health care dollars are
being spent on health education or the promotion of healthful behaviors and lifestyles or environmental
protections, while these factors may account for up to 71 percent of all preventable premature mortality before age 75.
Limitations of the health services research models and the resource-based planning models were
discussed and comparisons drawn with a health promotion model. Dr. Green noted that health
promotion includes environmental determinants of health in addition to lifestyle determinants.
Health promotion includes a combination of health education, policy, organizational and
regulatory strategies to bring about changes in behavior, lifestyle, and the environment conducive to health.
He noted that the development of health promotion strategies starts with people, not with diseases,
statistics, hospitals, doctors, or other resources. Health resources are tools, not ends to be maintained
regardless of their appropriateness to meet needs. Health education and health promotion also are means,
not ends. But health education and health promotion have greater potential than medical resources to start
where people are in their normal living rather than in the crises of living and dying. "Health education puts life
back into health by bringing people back into our planning and health promotion processes."
Following these presentations, the remainder of Day I and the morning of Day II were devoted to discussion of
research issues and identification of oral health promotion research opportunities. Working group recommendations
were presented and discussed in a plenary session on the afternoon of Day II.
Subsequent to the meeting, intramural staff prepared written summaries and transmitted them to all
participants for editing or revisions. Through email and written exchanges occurring over the next
three months, recommendations were revised and refined. Drs. Atchison and Green reviewed multiple
versions of the recommendations, to ensure that the key points developed at the workshop had been fully
addressed.
WORKING GROUP RECOMMENDATIONS
Health Promotion Interventions in Diverse Populations
Charge
This group identified unique opportunities for oral health promotion research within culturally or economically
diverse populations, emphasizing population subgroups at higher risk of poor oral health status or with limited
access to health care (e.g., educationally and economically disadvantaged, uninsured, rural or inner-city).
Background
Evidence from studies outside and inside the U.S. confirms significant disparities in health status between
population subgroups. For both oral and systemic health, poorer health status is strongly associated with having
less than a high school education and lower socioeconomic status (SES). In general, measures of both morbidity
and mortality differ as a function of SES. Heart disease risk, for example, has been found to be 2.5 times higher
in the U.S. among individuals in lower grade occupations. In 1990, 41 percent of individuals aged 65-74 in the
U.S. with less than a high school education were edentulous, as compared with 13 percent of individuals
of the same age with some college education. Death rates (corrected for age at death) observed in
members of the lower SES groups are approximately double those seen in upper SES subpopulations.
Disparities in health status persist even when barriers to health care are reduced through the
introduction of low-cost or no-cost health insurance. Recent data suggest that SES-related disparities
in health status within the U.S. population have actually increased over the past decade.
While reasons underlying these differences remain poorly understood, several factors appear to contribute.
These include a higher prevalence of life-style related risk factors for disease (e.g., tobacco use), lower rates
of involvement in health-promoting activities, failure to use preventive health services, less access to health
care services, higher rates of illiteracy which make media messages regarding health risks less accessible
or salient, and chronic environmental and social stressors and their impacts on biological as well as
psychosocial functioning. Thus, intervention research addressing socioeconomic and educational
determinants of impaired health could yield major health benefits and potentially reduce health
care costs. Throughout the discussion, the conceptual and methodological imprecision of using minority
group membership as a proxy for disadvantaged status was emphasized. Instead, inclusion of
appropriate, focused measures of social, economic, and educational disadvantage was recommended.
Rapid changes occurring currently in U.S. health care delivery, combined with the availability of new effective,
professionally delivered preventive technologies for oral diseases, suggest the need for vigilant attention to
changing patterns of health care services utilization within diverse populations, with specific intervention
programs aimed toward producing health-supporting patterns of utilization.
Research Recommendations
- Determine characteristics (e.g., socioeconomic, educational) identifying subpopulations with higher prevalence of oral diseases and focus intervention research around the specific health risks (e.g., behaviors, environmental factors) identified within these subpopulations.
- Use secondary data analyses to aid in developing information regarding the health status or health-influencing behaviors of diverse population subgroups. Secondary analyses may contribute to identifying population subgroups likely to benefit from interventions and may contribute to structuring appropriate intervention models and outcome measures.
- Characterize changes in health indices or in health-related behaviors across diverse population subgroups. Such information is needed to prioritize and shape interventions (e.g., Are members of a defined group showing positive changes in indices of health or health-supporting behaviors which mirror the larger society, or failing to match improvements seen in other population subgroups?)
- Determine critical points within the life span when interventions relevant to specific oral health problems could influence life long health. (For example, high school dropouts, irrespective of their ethnic or racial backgrounds, show demonstrably less favorable oral and general health characteristics over their life trajectory. What causal factors contribute to these differences? Can interventions in childhood, adolescence or early adulthood reduce these alterations in risk and health status which typically persist for a lifetime?)
- Identify conditions under which individual-level vs. collective-level interventions should be given preference, and conditions under which both types of approach can be integrated effectively. Attention also should be directed to conditions under which effective individual-level change models can be expanded or scaled up to group or community levels.
- Include measures of socioeconomic status, literacy, and other indicators of social or educational disadvantage in clinical trials assessing new technologies or preventive/therapeutic interventions directed toward improving oral health. Such information will aid in determining whether technologies or interventions are appropriate within diverse contexts or need modification to better address the needs of diverse subpopulations and/or diverse health care provider groups.
- Determine the impact of oral health care systems on the oral health of disadvantaged individuals. For example, the impact of various kinds of financing systems and patterns of health care delivery need to be related to indices of health outcome or health status in targeted subpopulations, as well as in the total population.
- Develop and evaluate both primary and secondary prevention interventions to improve oral health outcomes, oral function, systemic health, or health-related quality of life in special care populations (e.g., HIV+ persons, cancer patients, individuals with genetic disorders producing craniofacial disfigurements).
- Encourage the use of participatory health research perspectives, methods, and techniques. In the absence of such special efforts, access to and retention of diverse study populations will be compromised.
- Develop new research alliances and partnerships focusing on oral health promotion. Partnerships and alliances could, for example, include diverse communities characterized by poorer health status, organizations serving such populations, government agencies supporting health research and educational research, other research funding agencies, private foundations, and private industry.
- Encourage investigators to enter the area of oral health promotion with diverse populations. Special emphasis should be placed on research training and structuring research initiatives which foster diversity within the pool of investigators planning and implementing health promotion research.
Community Interventions
Charge
This working group identified research opportunities related to community-based approaches used to
promote oral health outside traditional health care delivery settings. For example, interventions may
involve use of the mass media to encourage health-related behavioral changes, health-relevant organizational
or policy changes, community-wide interventions, or community-based approaches to promote oral health
or provide screening and early detection of oral diseases.
Background
Community interventions are implemented largely outside health care settings.
Community interventions can either be community-wide or community-based. Community-wide
interventions are implemented within total communities, relying upon the community itself as the unit of analysis when
evaluating outcomes. A coordinated program of public education, media campaigns, communications directed toward
health providers, or other key decision makers, and other broadly-based interventions aim to produce small but pervasive
health-related changes within the population at large. Target behaviors might include, for example, smoking cessation,
dietary changes, increased blood pressure screening, more prompt seeking of care following symptoms, or combinations
of health-supporting behaviors. Typically, community-wide interventions do not attempt to identify higher risk groups
or individuals or to target resources to those most likely to benefit. The underlying rationale is that the net effect of
achieving a small percentage change in an entire population yields a more profound public health effect than would
strategies aimed at the relatively small percent (e.g., 10-20 percent) of the population at particularly high risk for
the disease of interest. Cardiovascular and cancer community intervention trials initiated by the NIH in the 1970s
and 1980s represented pioneering efforts in community-wide health promotion programs.
Community-based interventions are also conducted within the community and require community participation and
support. They do not, however, focus on the entire community as the unit of analysis. Instead they focus on targeting
interventions to groups comprised largely of individuals with poorer health status and/or higher health risks.
In devising community-based interventions, relative disease risk patterns will influence selection of specific
community sites and help direct intervention aims.
Health promotion interventions have been categorized as reactive, responsive, or planned,
with each category differing substantially in goals, content, and impacts. In general, the planned model for intervention
presents the preferred model for developing scientific knowledge. The current NIH review structure strongly favors
planned interventions, which typically involve substantial participation from community members.
Controversies and policy changes concerning community intervention research were discussed. Specifically,
agencies that had served as the vanguards for ambitious, large, costly community-wide trials (e.g., NHLBI)
now report that their research strategies are shifting towards community-based interventions targeting higher
risk subpopulations. Particularly in the case of cardiovascular community research, this reflects relatively
consistent findings (Winkleby, M.A., 1994; Schooler, C, Farquhar, J.W., Fortmann, S.P., and Flora, J.A., in press; Susser, 1995)
that community-wide interventions directed toward improving cardiovascular health produced negligible,
or at best very modest, benefits. This is thought to reflect profound, unexpected secular trends in health-influencing
behaviors (e.g., diet, exercise) generating major health improvements within control communities, as well as in
experimental communities.
It should be noted, however, that subgroup analyses from these same trials indicates that the less
highly educated, socioeconomically disadvantaged members of the control and experimental communities
did differ substantially on post-intervention measures. These subgroup differences were offset in community
level analyses by the comparability of behaviors and health outcomes found in college-educated participants.
The Community Interventions Workgroup developed both the generic recommendations and illustrative disease-specific
(oral cancer) research recommendations listed below:
Research Recommendations
- Develop and evaluate various models of community-based screening for oral diseases (e.g.,
oral cancers, nursing caries) or oral markers of systemic diseases. Identify strategies through
which the broader community can receive health education messages (e.g., media announcements)
in association with the screening interventions. Determine the benefits of embedding oral health
information within broader health information contexts.
- Identify key elements involved in successful implementation of research requiring community partnerships:
- Determine modes of citizen partnership and approaches for gaining access into the community, as these relate to the feasibility of conducting research and the quality of research outcomes;
- Identify relationships between and among community structures and the feasibility and effects of various models for health promotion (e.g., leveraging, coalitions, lead agencies, empowerment);
- Develop and evaluate the full range of perceived health needs in the community (these may not match the researchers' priorities);
- Develop techniques for developing community resources that permit successful implementation of the intervention, dissemination of findings within the community, and also encourage continuing, self-sustaining benefits to the community's health.
- Determine how various types of service delivery innovations (e.g., managed care) can be utilized or assessed as a component of community-focused health promotion interventions;
- Develop interventions and assess outcomes which result from involving largely non-health directed
community institutions (e.g., churches, libraries, schools, senior centers) in participatory health
promotion research, such as:
- Providing health information (e.g., risks for fetal alcohol syndrome; nutrition defects, risk factors for oral cancers);
- Hosting and participating in interventions for health-supporting behavior change (e.g., smoked or smokeless tobacco cessation; sports injury prevention with appropriate headgear);
- Stimulating appropriate referrals for oral health care or comprehensive health care;
- Conducting periodic screenings (e.g., periodontal disease, oral cancers, nursing caries);
- Providing follow-up support and reinforcement, especially for individuals with other chronic co-morbidities.
- Determine how new information technologies (e.g., health cable channels, community-based access to computer networks) or targeted media campaigns (e.g., radio stations or local newspapers reaching diverse communities or affinity groups) can provide health information or contribute to community-based health promotion.
- Identify the characteristics and mutability of ecological and economic factors influencing policies, decisions and behaviors which directly impact upon oral disease prevention or oral health promotion (e.g., community water fluoridation).
Oral Cancer Prevention Research Recommendations
A collateral set of research recommendations developed by this group focused on preventing oral cancers and encouraging early detection of oral cancers -- priority areas of interest for the NIDR. Both community-based and practice-based research approaches were included.
- Develop, implement and evaluate a national campaign to raise health care provider and public awareness of the risk factors for, and signs and symptoms of, oral cancers; increase recognition of need and appropriateness of provider/individual behaviors as related to periodic oral cancer examinations.
- Develop, test, and contrast method(s) and approach(s) to increase the quantity and quality of oral cancer examinations received by high-risk individuals.
- Develop reliable, valid measures of health care providers' skills in conducting appropriate physical examinations for oral cancers; identify characteristics of providers' diagnostic decisions and referral behaviors as related to appropriate detection of oral cancers; conduct interventions to increase the quality of practitioners' diagnostic decision making and referral;
- Improve and assess training procedures for oral cancer self-examination as these relate to the frequency and quality of laypersons' implementation of self-examination methods.
- Determine the feasibility, costs, and benefits of including oral cancer screening examinations with other cancer screenings (colorectal, cervical, prostate, breast) performed by nurse practitioners and physicians;
- Determine the impact of the availability and use of new screening technologies (e.g., Toluidine Blue) upon: a) stage of cancer at diagnosis; b) thoroughness of oral cancer examinations; and c) number and kinds of health care providers performing oral cancer examinations.
Health Care System-Based Health Promotion/Science Transfer
Charge
This group evaluated research needs related to the diffusion of sound health-promotion information to
the general public, patients, health care providers, and educational institutions. This included consideration
of the role of preventive guidelines, computer-based decision support systems, and other innovative
approaches which could contribute to adoption of effective disease preventive strategies within health
care delivery, as well as special research needs related to diffusion and science transfer.
Background
Health Care Delivery System-Based Oral Health Promotion
The provision of health care provides many opportunities for disseminating health-promoting
information and for implementing health-promoting or disease-preventing interventions. These opportunities exist because:
- Health care providers are typically perceived by patients to be credible and reliable sources of health-related information;
- Improved health outcomes are the primary goal of all activities undertaken in this setting. Consumers recognize this as a setting in which health care providers are expected to offer interventions contributing to the consumer's or patient's comfort, function, and health;
- Some disease-preventive procedures (e.g., pit and fissure sealants) are delivered exclusively in health care settings;
- Some level of continuity (doctor-patient relationship, medical records) typically characterizes health care delivery, thus providing special opportunities for detecting health changes and monitoring health-related behavioral changes over time.
Dental care provides many opportunities for "teachable moments" (i.e., opportunities to capture patients'
attention and convey information with maximum impact). Examination of oral soft tissues and
periodontal examinations, for example, provide natural opportunities for discussing biological effects
of tobacco and risk factors for disease. Other team members can reinforce health information provided.
The few studies available indicate that tobacco cessation programs offered in dental settings are accepted
well by patients and highly effective, relative to tobacco cessation programs offered in other health care
settings. This information has not yet had a broad impact on health care delivery despite the obvious
potential it has for involving practice-based dentists and dental hygienists in health-promoting interventions.
Practice-based health promotion research in medical settings indicates that use of enabling strategies
(e.g., office reminders), reinforcing strategies (e.g., feedback), and predisposing strategies (e.g., practice
guidelines) substantially increases the likelihood that physicians implement educational or preventive
interventions for their patients. Nevertheless, even in practice settings where physicians are
reminded to screen and intervene and where appropriate practice guidelines and supportive
educational materials are available, physicians typically do not implement all the strategies they
have learned. Interventions that involve both other health care team members and physicians
have been found to be most consistently effective.
Incentives within the health care system influence the success of changing health-promoting behaviors in health
care providers, the public, educators, and others. How do existing disincentives (e.g., financial) in the health
care system impact on oral health promotion efforts? How best should one use incentives coupled with
science-based evidence to leverage health providers, third-party payers, and others to change reimbursement
plans to emphasize health-promoting behaviors and practices? Research is needed to identify the most
effective approaches to encourage sustainable health care system-based oral health promotion.
Diffusion/Science Transfer
Achieving improvements in oral health and preventing oral diseases and debilitating conditions requires that
the public and health care providers utilize appropriate disease-preventive interventions and strategies.
Yet large gaps persist between research findings and clinical practice.
Diffusion (i.e., information transfer, science transfer, or information dissemination) has been defined as the
science and art of information transfer, with adoption of new knowledge, interventions, and practices by various
stakeholders. The application of research results--science transfer--is crucial to the success of health
disease prevention efforts.
Much of the earlier research on diffusion of medical innovations focused on profession-wide diffusion of
expensive medical technologies, new procedures, or drugs. Recent studies emphasize dissemination of
clinical guidelines to health care workers, as these relate to the patterns and quality of health care provided.
While a significant number of studies have examined diffusion of preventive technologies and practice
guidelines in medicine, diffusion or health promotion/disease prevention technologies or practice guidelines
have received minimal scientific attention in dentistry.
Research Recommendations
Health Care Delivery System-Based Health Promotion
- Develop improved instruments or measures for use in assessing dental provider and consumer readiness for behavioral change, especially within the context of health care delivery.
- Investigate factors influencing health care providers' and the public's adoption, implementation, and maintenance of successful oral health-promoting strategies.
- Conduct research to identify and adapt existing "best practices" models of health-promoting strategies or health care system-based oral health promotion programs. Consider adopting health promotion/disease prevention strategies that have been found to be successful in addressing other health problems (e.g., diabetes and hypertension).
- Develop and test strategies to overcome barriers to providing health education, screening, preventive interventions, or behavior-change interventions within practice settings. Such barriers include perceived lack of time, perceived or actual cost disincentives, practitioner-patient roles and responsibilities, and perceived lack of ability to influence patients' behaviors.
- Develop and test strategies for integrating oral health interventions and other interventions to improve health or functioning.
- Develop and test strategies for incorporating oral health-promoting practices in non-dental health care settings or programs (e.g., physicians' offices, hospital settings, nursing homes, and public health departments; and early childhood programs).
- Develop resources and assess the effects of using multimedia technologies (e.g., interactive multimedia) or other information technologies to transfer scientific or health-related information to both practitioners and the public.
- Develop strategies for integrating new information technologies (e.g., interactive multi-media) into health care delivery settings.
- Encourage the development of an expanded infrastructure to support and disseminate information regarding oral health promotion research. Such an infrastructure could include professional schools, scientific organizations, professional organizations, professional and community networks, health care practitioners, Federal agencies, and perhaps also international components. Collaborate with other federal health promotion efforts or information technology resources (e.g., NIH's Library of Medicine) to lessen the burden of start-up costs.
Diffusion/Science Transfer
- Determine critical characteristics and processes that influence science transfer to health providers, as well as to patients.
- Investigate the major determinants (e.g., clinical trial evidence, incentives, published findings, and prevailing "social culture" of dental/medical practice) influencing oral health professionals and other health care professionals' readiness to change their own behaviors which influence oral disease prevention or health promotion.
- Determine how best to accumulate, summarize, and disseminate evidenced-based information relevant to health promotion.
- Identify current and potential impediments and incentives within the health care system for adopting and using more effective preventive technologies. Conduct intervention research to test the feasibility and cost-effectiveness of strategies to overcome identified impediments.
- Explore the feasibility of developing a centralized, multidisciplinary focus for collecting research or research resources in science transfer, and existing clinical practice guidelines (e.g., dentistry, nursing, medicine) relevant to preventing oral diseases or preserving oral function.
Measuring Impacts of Health Promotion Interventions
Charge
This work group examined research needs and methodological issues to measuring intervention outcomes
at both the individual and population level (e.g., indices of oral or systemic health, physical and/or social
functioning, health-related quality of life, and economic impacts).
Background
Interventions can only be assessed if sound outcome measures are available. Such measures need to be reliable,
sensitive, and appropriate both to the questions being asked and the study populations. The availability of such measures
can accelerate research progress. Expanded interest has emerged over the past two decades in assessing health outcomes
associated with both medical and dental treatments.
This interest reflects several societal concerns. Health care costs have been rising dramatically in most countries
regardless of the structure of their health care systems. Measuring outcomes provides the basis for determining
whether scarce resources are being directed towards the most effective treatments available. As chronic
health conditions in aging populations increasingly come to dominate health care delivery worldwide, goals
of treatments have begun to shift toward minimizing disease progression and maintaining function and quality
of life (i.e., secondary prevention and symptom management). Thus, mortality endpoints become less relevant
to the objectives of health care, while qualitative outcome measures (e.g., functioning and quality of life) become
more central.
This working group recognized the pivotal role that improved measurement of outcomes could play in accelerating and
strengthening implementation of an NIDR intervention science/prevention science agenda.
Research Recommendations
- Develop and validate measurement approaches and methodologies, particularly those fostering integration of information for general health and for oral health.
- Test generic health status indicators (e.g., Sickness Impact Profile), or modifications of widely used generic measures, for use in oral health studies. Use of generic measure would help ensure comparability with outcome measures used in other areas of health.
- Develop sensitive, reliable measures of oral function and social impacts of oral health (e.g., chewing function, orofacial appearance).
- Develop both individual and societal measures of outcomes; societal measures producing aggregate data will be particularly useful for evaluating policies and population trends.
- Determine the complexity and number of outcome measures needed to address specific research issues. (Increasing the complexity or number of outcome measures may be neither helpful nor necessary. For example, a current NHLBI-supported community intervention trial on myocardial infarction uses a single outcome measure--the number of minutes elapsing between the patient's perceiving symptoms and presenting for medical care).
- Modify or revalidate outcome measures for use with diverse population subgroups. Levels of literacy, either in English or in other languages, should be evaluated in conducting research within community settings or with diverse populations.
- Evaluate the extent and characteristics of associations between clinical indicators of disease or response to interventions (e.g., periodontal pocket depth, bleeding measures) and qualitative or patient-generated indicators reflecting functional or psychosocial impacts of diseases or interventions. (Such qualitative outcomes are more salient to the patient in judging whether the intervention was "successful", determining whether to comply with recommended treatments, or whether to seek additional care. For these same reasons, qualitative measures may often be more relevant to policy decisions than are clinical indicators).
- In assessing new technologies or interventions, include both patient-generated qualitative indicators of outcome as well as clinical outcome measures.
- Identify relationships between earlier surrogate measures of disease and disease endpoints in evaluating clinical outcomes of measures. This type of information is particularly critical if endpoints (e.g., tooth loss) providing the ultimate basis for determining success of the intervention occur long after the intervention was implemented.
- Validate measures and indicators within populations of appropriate ages, to determine whether the measure is sensitive to the impact of oral conditions at different stages within the life cycle. Scales developed specifically for studies of adult or older adult populations, for example, will emphasize conditions (e.g., tooth loss, advanced periodontal diseases, or other age-specific conditions) less relevant to other age cohorts.
- Standardized, broadly accepted methodologies are needed to evaluate the cost benefit and cost effectiveness of both preventive and therapeutic interventions.
- Measure not only short-term effects, but also longer-term effects to determine whether intervention effects persist. Research funding agencies should evaluate the need for long-term follow-up on all intervention projects they support, in order to ensure maximum benefits from the studies supported.
- Wherever feasible, archival records for research data should be established and made available to other investigators, providing opportunities to share detailed information regarding the strengths and limitations of different outcome measures. This will facilitate comparisons of intervention outcomes across populations and research sites.
Cross Cutting Recommendations
Recommendations generated independently within at least three of the working groups are summarized below:
- Risk Groups
The highest research priority should be assigned to interventions directed toward individuals and population subgroups at highest risk of oral diseases. There is an urgent need to develop new approaches which will help ensure that all segments of our society realize the health gains now made possible by technological and research advances.
- Health Care Delivery System
Existing patterns and norms in health care delivery, as well as incentives within the health care delivery system,
are often inconsistent with requirements for effective health promotion and disease prevention. Health promotion
research directed toward identifying and removing impediments and barriers within the health care delivery system
is urgently needed.
Efforts to conduct health promotion research or disease prevention research within managed care settings
should be specifically encouraged.
- Peer Review
Health promotion/disease prevention research is not well served by the current DRG grant review system.
If work in this area is to flourish or expand, the NIH must make an appropriate commitment to assuring adequate,
knowledgeable peer review.
- Establishing Ongoing Health Promotion/Disease Prevention Working Groups or Advisory Committees
If NIDR anticipates a major expansion of efforts in these areas, establishing at least one committee with an
ongoing charge to identify collaborative research opportunities and additional research strategies would be helpful.
Various committee configurations could be considered. Participation from other Institutes, foundations,
and industry should be planned.
- Opportunities for Collaborative Research with other Institutes, Foundations, and Industry
Excellent opportunities for co-funded research exist, but they will need to be pursued vigorously and consistently to ensure success.
Oral cancer represents one particularly promising topic for collaborative research.
- Research Training
Research personnel issues will need to be addressed if this area is to expand. Appropriate research
training programs should be developed and supported.
RESPONSES FROM INDUSTRY AND AGENCY REPRESENTATIVES
Participants from other NIH Institutes, other PHS or science agencies, professional organizations, and industry were invited
to share additional insights. In general, their comments reflected shared scientific interests and enthusiastic recognition
of opportunities for collaborating on health promotion research initiatives. Highlights of comments from representatives
outside NIH are summarized below:
- Indian Health Service (IHS)
Dr. Eric Bothwell - IHS staff is eager to cooperate. They have data systems in place with oral and medical
clinical data, treatment records, and some sociodemographic data. One focus could be on the association
between diabetes and certain oral diseases. Specific Indian populations (e.g., the Pimas) show the highest
prevalence and incidence of non-insulin dependent diabetes in the world. They also show high rates of obesity
in childhood, early onset diabetes, early childhood caries, and severe periodontal needs.
IHS has suffered substantial reductions in per capita funding for Native-American health care due to
decentralization and turnover of some funds to tribal control. Funds available have been shifted from health
promotion/disease prevention to urgent care. IHS welcomes research partnerships, particularly those
including some support for infrastructure or amplified efforts to improve disease prevention and health
promotion in these special populations.
- Health Resources Services Administration (Community Migrant Health Centers)
Dr. Jay Anderson - Community health centers provide unique opportunities for partnerships involving studies
of economically disadvantaged populations seen within the framework of culturally sensitive, community-based
health care. Community Migrant Health Centers serve diverse populations. While both staff and community
members actually show strong interest in preventing disease, participation in research or preventive interventions
is likely to be heightened if dental services are also being provided or if research participation can be coupled
with the delivery of services. Possibly, availability of quality dental services at low cost would be an effective
inducement to recruit and maintain other disadvantaged community members in oral health promotion or
general health promotion projects.
- Agency for Health Care Policy and Research (AHCPR)
Dr. William Maas - NIDR and AHCPR have several overlapping interests. Both agencies seek to determine
how health care professionals can be encouraged to engage in behaviors or clinical decisions that
produce improved outcomes for patients. The NIDR and AHCPR have collaborated both administratively
(scientific review of projects outside the expertise of typical NIH study sections) and scientifically
(clinical decision making, outcomes assessment). Research findings on topics of primary interest to AHCPR
(e.g., insurance programs, managed care programs) may contribute to defining a disease prevention or
health promotion research agenda or lead to joint health promotion initiatives.
- National Science Foundation (NSF)
Dr. Phyllis Everist - NSF does not fund disease-oriented research. However, it does fund basic scientific
research in the behavioral and social sciences, as well as other sciences. If topics in basic science research
are identified which need to be resolved to move forward on an oral health promotion agenda, NSF could
collaborate by supporting that basic research.
- Centers for Disease Control and Prevention (CDC)
Dr. Leandris Libird - Diabetes control programs are supported at the state and territorial level in all fifty states.
Oral health promotion could be included in these programs, but is not now. The CDC Division of Diabetes
Translation is currently collaborating with NIDDK to launch a new diabetes prevention program.
This may present opportunities for additional collaborative efforts focusing on oral health promotion
in the context of diabetes prevention and control.
- Agency on Aging (AOA)
Ms. Albarelli - Opportunities exist to collaborate within a well-organized infrastructure of health and other services
being provided to older individuals. These include state and territorial units on aging, area agencies on aging,
and networks of service providers oriented toward problems associated with aging. In addition, AOA supports
221 grants with Indian tribes, providing an additional route of access to a minority group with many health problems
including oral health.
- International Representatives
Dr. Peter Davis (New Zealand) - Dentistry needs to integrate horizontally with other health professions
reaching out to the community; collaborative health/oral health programs should be identified and developed.
For example, while diabetes and asthma are recognized as major health concerns in New Zealand,
oral health issues are seen as less urgent. This suggests opportunities to advance oral health through
integrating oral health promotion into programs to improve management of diabetes.
Dr. David Barmes (Special Expert for International Health, NIDR) - We need to evaluate new ways
to get health promotion and prevention information to deprived and/or under-served populations --
both nationally and internationally. This is a concern in both highly industrialized countries and in
deprived countries with special barriers to optimal health and health care. We also need to align
oral health promotion with other health concerns (e.g., cancer or diabetes).
- Foundations/Industry
Dr. John Clarkson (IADR/AADR) - Many countries have developed their own strategic plans in oral health
promotion (e.g., WHO Goals for Oral Health). Exchanging these plans could help accelerate progress;
we need to take full advantage of opportunities to learn from each other. An NIDR research agenda
in oral health promotion could be of interest both nationally and internationally. The IADR's Behavioral
Science Health Services Research Group would specifically welcome such a research agenda.
Dr. Christopher Fox (Colgate) - Private industry is interested in oral health promotion and currently supports
some health promotion activities. For example, Procter and Gamble provides patient education materials for
dental offices. Also, Colgate is currently conducting a health promotion effort ("Bright Smiles-Bright Futures")
aimed toward improving oral health attitudes and behaviors in school children (Oakland, CA). Private industry
has available funds, has access to desired communities, and is very interested in collaborating on oral health
promotion research projects.
WORKSHOP CO-CHAIRS
