Pediatric Obesity Management in Rural Clinics in California and the Role of Telehealth in Distance Education

Objective: To determine health care provider needs related to pediatric obesity management in rural California and to explore strategies to improve care through telehealth. Methods: Cross‐sectional survey of health care providers who treated children and adolescents at 41 rural clinics with existing telehealth connectivity. Results: Most of the 135 respondents were family physicians at designated rural health clinics serving low‐income families. Respondents had practiced in rural areas for an average of 10 years. Most providers rated their self‐efficacy in managing pediatric obesity as 2 or 3 on a 5‐point scale. The barriers most frequently reported by health care providers were lack of local weight management programs, lack of patient motivation, and lack of family involvement in treatment. Providers reported that the resources they would find most helpful were readily accessible patient education materials, strategies to link patients with community treatment programs and training in brief, focused counseling skills. Three‐quarters of providers already used telehealth for distance learning. Providers reported very high interest in participating in continuing education on pediatric obesity delivered by telehealth, specifically Internet communication with specialists, web‐based education, and interactive video case‐conferencing. Conclusions: Rural health care providers face several barriers related to pediatric obesity management. Targeted interventions provided via telehealth to rural health care providers may enhance the care of obese children and adolescents. The results of this study provide directions and priorities for the design of appropriate interventions.     

Parent or caregiver, staff, and dentist perspectives on access to dental care issues for head start children in Ohio

OBJECTIVES: We conducted 5 surveys on consumer and provider perspectives on access to dental care for Ohio Head Start children to assess the need and appropriate strategies for action. METHODS: We collected information from Head Start children (open-mouth screenings), their parents or caregivers (questionnaire and telephone interviews), Head Start staff (interviews), and dentists (questionnaire). Geocoded addresses were also analyzed. RESULTS: Twenty-eight percent of Head Start children had at least 1 decayed tooth. For the 11% of parents whose children could not get desired dental care, cost of care or lack of insurance (34%) and dental office factors (20%) were primary factors. Only 7% of general dentists and 29% of pediatric dentists reported accepting children aged 0 through 5 years of age as Medicaid recipients without limitation. Head Start staff and dentists felt that poor appointment attendance negatively affected children's receiving care, but parents/caregivers said finding accessible dentists was the major problem. CONCLUSIONS: Many Ohio Head Start children do not receive dental care. Medicaid and patient age were primary dental office limitations that are partly offset by the role Head Start plays in ensuring dental care. Dentists, Head Start staff, and parents/caregivers have different perspectives on the problem of access to dental care.     

Emergency Department Coverage by Primary Care Physicians in a Rural Practice-Based Research Network: Incentives, Confidence, and Training

ABSTRACT:  Context: In rural areas of the United States, emergency departments (EDs) are often staffed by primary care physicians, as contrasted to urban and suburban hospitals where ED coverage is usually provided by physicians who are residency-trained in emergency medicine. Purpose: This study examines the reasons and incentives for rural Oregon primary care physicians to cover the ED and their reported measures of confidence and priorities for additional training. Methods: We conducted a cross-sectional survey of primary care physicians in rural Oregon who are members of the Oregon Rural Practice-Based Research Network (ORPRN). The survey was sent to 70 primary care physicians in 27 rural Oregon practices. Findings: Fifty-two of 70 (74%) ORPRN physicians representing 24 practices returned the questionnaire. Nineteen of the 52 responding physicians reported covering the ED. The majority (75%) of physicians covering the ED did so as a requirement for practice employment and/or hospital privileges. Physicians covering the ED reported low confidence in pediatric emergencies and expressed the need for additional training in pediatric emergencies as their top priority. Conclusions: Almost two fifths of surveyed primary care physicians in a rural practice-based research network provide ED coverage. Based on these physicians' low levels of confidence and desire for additional training in pediatric emergencies, effective education models are needed for physicians covering the ED at their rural hospitals.     

Short‐stay rural and remote placements in dental education,an effective model for rural exposure: A review of eight‐year experience in Western Australia

Objectives: The increase in demand for dental care over the next 10 years is expected to outstrip the supply of dental visits in Australia, resulting in an ongoing shortage of dental practitioners. As trends in medicine have shown, the greatest effect will be felt in rural and remote regions, where an undersupply of dentists already exists. It is clearly evident that it is important to provide strategies that will increase the recruitment and retention of practitioners in rural and remote areas. Previous research suggested an increased likelihood for health graduates to choose rural practice if they have a rural background, or were exposed to rural practice during their education. Short‐stay (three to four weeks) placements for final‐year dental students has been part of dental education in Western Australia for near on a decade. Methods: This paper reflects on the experiences gained from managing this placement program. Conclusions: Short‐stay placements are a quality learning initiative but need a high level of planning and a clear vision to be effective. Implications: The key factors in ensuring sustainable, student centred learning is driven through a small core group of staff who have strong direct links with rural and remote communities, students and support providers. The integration of service, education and research goals have played a critical role in sustaining placements. The philosophy underpinning the rural placements needs to be clearly articulated and applied effectively in each step of their implementation and a highly focused customer‐service driven implementation is required to make short‐stay rural and remote placements effective.     

Dental care provision by students on a remote rural clinical placement

Background: In 2009, the School of Dentistry and Oral Health, Griffith University, commenced a clinical placement in a remote rural and Indigenous community in Australia. This paper analyses the type of treatment services provided from 2009 to 2011 by year, type of patient and age of patient. Methods: All treatment data provided were captured electronically using the Australian Dental Association (ADA) treatment codes. Audited reports were analysed and services categorised into six broad treatment types: consultation, diagnostic, preventive, periodontics, oral surgery and restorative services. Results: The bulk of dental care episodes provided over the three‐year period were for clinical examinations, restorative and oral surgery services. Preventive and periodontic services generally comprised less than 10% of the care provided. Over time fewer clinical examinations were conducted and restorative dentistry increased in the second and third years of the placement. There were no significant differences in the types of care provided to public and private patients. Conclusion: Clinical placement of final‐year dental students in remote rural settings has helped address a largely unmet dental need in these regions. Implications: Dental student clinical placement is effective in providing care to communities in a remote rural setting. Student placements are, however, only able to deliver dental care in few remote rural communities, and therefore will make a negligible impact on the level of untreated dental disease in the short term. It is hoped that the experience will lead to more graduates serving some of their professional lives in remote communities.     

Emergency department reliance among rural children in Medicaid in New York State

Abstract Purpose: This study examines variation in emergency department reliance (EDR) between rural and metro pediatric Medicaid patients in New York State for noninjury, nonpoisoning primary diagnoses and seeks to determine the relationship between receipt of preventive care and the likelihood of EDR. Methods: Rural/urban designations were based on Urban Influence Codes established by the United States Department of Agriculture (USDA). Healthcare Effectiveness Data and Information Set (HEDIS^®) well‐visit measures were calculated using 2008 Medicaid claims and encounter data. Well‐child numerator status and location of residence variables were then entered as independent variables in multivariate logistic regression models. Models controlled for the effects of Medicaid financing system (fee‐for‐service vs managed care), Medicaid aid type, race/ethnicity, gender, and 2008 clinical risk group category. Findings: The likelihood of EDR was higher in all age categories for rural compared to metro residing Medicaid children in New York State. Meeting HEDIS well‐child criteria was protective against emergency department (ED) reliance in the adolescence age group (OR = 0.84). Conclusion: ED reliance is associated with rural residence. Increased access to primary and specialty care in rural settings could help reduce EDR, particularly among rural adolescents.     

Disparities in regular source of dental care among mothers of medicaid-enrolled preschool children

For mothers of Medicaid children aged 3 to 6 years, we examined whether mothers' characteristics and local supply of dentists and public dental clinics are associated with having a regular source of dental care. Disproportionate stratified sampling by racial/ethnic group selected 11,305 children aged 3 to 6 in Medicaid in Washington State. Mothers (n=4,373) completed a mixed-mode survey that was combined with dental supply measures. Results reveal 38% of mothers had a regular dental place and 27% had a regular dentist. Dental insurance, greater education, income, length of residence, and better mental health were associated with having a regular place or dentist for Black, Hispanic, and White mothers, along with increased supply of private dentists and safety net clinics for White and Hispanic mothers. Mothers lacking a regular source of dental care may increase oral health disparities disfavoring their children.     

The challenges associated with providing community care for people with complex needs in rural areas: a qualitative investigation

The aim of the present study was to explore the experiences of recipients and providers of community care in rural areas in Northern Ireland. Additionally, the authors sought to examine the impact of location, housing and environmental factors on the delivery of community care to older people with complex needs. Individual, semistructured interviews were held with service users (n = 17) and family carers (n = 14). Individual and focus group interviews were conducted with care assistants, health and social care professionals, and senior managers from a large health and social care trust and health and social services board in Northern Ireland. The importance of enabling older people to remain in their own homes and communities was emphasised by all participants. The main challenges associated with care provision in rural areas included: difficulties recruiting care assistants; lack of choice of care assistants; isolation; travel and distance between clients and their care assistants; and poor housing conditions. There was a general consensus among participants that the effectiveness of rural community care was perceived to be reliant upon the goodwill of the community. Additionally, changing demographic trends and the predicted shortfall in the number of formal and informal carers were considered key issues for service planners. A number of creative strategies could be used to address many of the limitations associated with rural isolation. These should involve capitalising on available community networks. However, planners should also acknowledge that additional resources are required to maintain older people in rural communities.     

Adherence to an oral health program for HIV infected children and adolescents and the attitudes of their caretakers

This study aimed to evaluate the adherence to an Oral Health Program (OHP) for HIV infected children and adolescents, as well as the attitudes of their caretakers regarding oral care. A total of 58 caretakers that accompany the children in medical appointments at an AIDS ambulatory were interviewed for collecting personal data and data regarding adherence to the OHP or other odontological treatment and attitudes related to oral care. Approximately 70% of the caretakers stated that their children participated in the OHAP, however 20% of them did not return to the recall appointments; such visits were even less frequent when the caretakers were not the parents themselves (p= 0.036). The adherence of this population to dental treatment outside the OHP was small, 48% of the caretakers stated that the child did not conclude the treatment when referred to another place for treatment. The attitude of the caretakers regarding dental care of HIV+ children was not considered satisfactory. Furthermore, it is very important to have pediatric dentists in the multi-professional teams that attend HIV+ children and adolescents and to promote this program among the parents and all medical teams involved with such patients.     

广州市10~12岁儿童口腔健康相关行为现状

了解广州市儿童六龄齿免费窝沟封闭项目开展2~3年后10~12岁儿童口腔健康行为状况,为制定口腔健康工作重点提供信息支持.方法 于2014年9月采用多阶段分层随机整群抽样方法,抽取广州市12个区(县级市)149所小学19 071名五、六年级学生进行口腔健康行为问卷调查.结果 60.3%的儿童每天刷牙2次及以上;33.2%的儿童报告听说过含氟牙膏,其中目前使用含氟牙膏者占44.73%;27.11%的儿童使用过牙线;71.50%的儿童接受过窝沟封闭预防龋齿治疗;30.97%的儿童过去1年内拜访过牙医.城区儿童每天刷牙2次及以上、使用牙线、接受窝沟封闭、过去1年内拜访过牙医的报告率均高于乡村儿童,乡村儿童使用含氟牙膏报告率高于城区儿童(P值均<0.01).城乡儿童末次牙科就诊主要原因分布差异有统计学意义(x2=130.911,P<0.01),城区儿童因定期牙科检查及预防性措施到牙科就诊的比例高于乡村儿童.仅有7.66%的儿童选择请牙科医生治疗应对牙龈(牙床)出血;采取不理会态度应对牙疼,认为挺一挺就过去了的儿童占42.13%.结论 在继续大力推动窝沟封闭预防龋齿治疗措施的同时,应加大氟化物防龋的宣传力度,加强学生、学生家长及教师的口腔保健知识宣传,工作重点应放在农村地区.     

The Effect of Rural Residence on Dental Unmet Need for Children With Special Health Care Needs

BACKGROUND: Unmet need for dental care is the most prevalent unmet health care need among children with special health care needs (CSHCN), even though these children are at a greater risk for dental problems. The combination of rural residence and special health care needs may leave rural CSHCN particularly vulnerable to high levels of unmet dental needs. OBJECTIVE: To examine the effects of rural residence on unmet dental need for CSHCN. METHODS: We use the nationally representative National Survey of CSHCN Needs. We performed logistic regression to estimate the independent effects of rural residence on the likelihood of having an unmet dental need, using a measure of unmet need based on professional society recommendations and a measure based on parental report. RESULTS: Using either of the measures, a substantial percentage of CSHCN do not receive all needed dental care. Rural CSHCN are more likely to forgo needed dental care than their urban counterparts. Our results suggest that rural CSHCN have unmet needs for dental care due to both difficulty accessing care and because their parents do not recognize a need. CONCLUSION: Traditional access barriers for rural children, such as inadequate provider supply and lack of insurance, may increase unmet needs both directly and indirectly, through their effects on parents' perceptions of need. Reducing unmet needs for dental care in rural children with special needs will require addressing both access issues and parents' understanding of dental care need.     

The ABCDs of treating the most prevalent childhood disease

Dental caries is a potentially preventable infectious disease that, untreated, can cause significant morbidity requiring costly treatment. The Access to Baby and Child Dentistry (ABCD) program increases access to prevention and early treatment for Medicaid-eligible children aged younger than 6 years in Washington State.The program is a partnership of Washington Dental Service Foundation, the University of Washington School of Pediatric Dentistry, the state Medical Assistance Administration, and local stakeholders. Through training in pediatric dental techniques and enhanced reimbursement, ABCD equips and encourages dentists to serve young Medicaid patients. Family counseling increases oral care compliance and reduces no-show rates. Program evaluation demonstrates changing attitudes and behavior among participating families and dentists, with more young, low-income Washington children receiving oral health care.     

Practices and meanings of oral health: a qualitative study with mothers of children assisted at the Federal University of Santa Catarina

This research aimed to know oral health practices and meanings of mothers whose children were attended in the dental pediatric clinics of the Federal University of Santa Catarina. The qualitative method, case study, was used and data were collected by semi-structured interview. The studied population consisted of seven mothers that took their children to odontologic attendance at the university. It was observed that despite previous negative odontologic experiences, economic difficulties and pregnancy have also influenced those mothers to look for and adhere to dental care. The dental visits occurred, mostly, for curative assistance. The mothers took care of their children's teeth because it was considered a maternal responsibility, to prevent dental caries and their consequences, to avoid wasting money with expensive treatment and children's bad experiences with dentists. Mothers received information on the subject from dentists, doctors, nurses, schools, mass communication media and odontology students. Despite of their desire in taking care adequately of their children's health, those mothers don't always have favorable socio-economic conditions to put the obtained instructions into practice.     

Dental Therapists: Improving Access to Oral Health Care for Underserved Children

Disparities in dental health care that characterize poor populations are well known. Children suffer disproportionately and most severely from dental diseases. Many countries have school-based dental therapist programs to meet children’s primary oral health care needs.Although dental therapists in the United States face opposition from national and state dental associations, many state governments are considering funding the training and deployment of dental therapists to care for underserved populations. Dental therapists care for American Indians/Alaska Natives in Alaska, and Minnesota became the first state to legislate dental therapist training.Children should receive priority preference; therefore, the most effective and economical utilization of dental therapists will be as salaried employees in school-based programs, beginning in underserved rural areas and inner cities.The 2000 report of the surgeon general Oral Health in America noted,

What amounts to “a silent epidemic” of oral diseases is affecting our most vulnerable citizens—poor children, the elderly and many members of racial and ethnic minority groups.^1(p1)

This persistent epidemic has not been alleviated by continuation of the present dental care delivery system. A significant factor contributing to the inability of children to obtain adequate dental care is the shortage of accessible dentists.2 Expansion of the dental workforce to include dental therapists offers the potential for improvement.More than 14 000 dental therapists practice in more than 54 countries throughout the world, including New Zealand, which originated the concept; Australia; Canada; the United Kingdom; and, most recently, the United States, in Alaska and Minnesota.3–5 High school graduates are trained in a 2-year program to provide preventive and restorative dental care, usually for children. In some countries training is being extended to 3 years to incorporate both dental therapy and dental hygiene, and to provide treatment of adults as well as children.6,7Dental therapist programs have been studied extensively in a number of countries, and the quality of care, which includes preventive and restorative treatment for more than 90% of school-aged children through high school, has been consistently documented to equal care provided by dentists.8–10 School-based dental therapists are salaried public health workers, and the overall cost of providing care to children in schools is thus significantly lower than the cost of private dental care.11     

Health Services for Behavioral Problems in Pediatric Primary Care

The aim of this research was to explore primary care pediatricians’ experiences in delivering behavioral health services in their own practices within the Nebraska context. An online survey was sent to the 154 primary care pediatricians who are members of the Nebraska chapter of the American Academy of Pediatrics. Questions explored their management of behavioral problems, attitudes, and perceived barriers to providing behavioral health services in their practices. Seventy pediatricians completed the survey (47%). The majority of pediatricians reported seeing substantial numbers of children with behavioral problems. Eighty-five percent believed that most emotional and behavioral complaints could be managed by the pediatrician. Eighty-eight percent believed that the parents would prefer to receive services for their children’s behavioral problems in the primary care office. Most felt that their training in mental health issues was inadequate. Pediatricians in this survey feel that pediatric behavioral problems are best managed in the primary care office and perceive that parents also prefer this setting. Improving training in behavioral health in pediatrics is necessary to meet the delivery of much needed behavioral health care to children and families.     

A rural/urban comparison of the roles of the general practitioner in colorectal cancer management

Objective: To identify and compare the roles of urban, rural and remote general practitioners (GPs) in colorectal cancer (CRC) management. Design: Semistructured interviews exploring GP views of their role in CRC management. Setting: Urban, rural and remote general practices in north Queensland. Participants: Fifteen GPs in urban, rural and remote practice. Main outcome measures: Self‐reported roles in the management of CRC patients and factors influencing these roles. Results: All GPs, regardless of location of practice, played a role in diagnosis, referral, postoperative care, psychosocial counselling, follow up and palliative care. Involvement in treatment of CRC patients was only performed by remote GPs. In general, rural and remote GPs played greater roles in care coordination, clinical and psychosocial care. Rural and remote GPs were more heavily involved throughout the entire illness progression when compared with their urban counterparts. Conclusions: The results of this study indicate that rural and remote GPs in north Queensland play a greater role than urban GPs in the management of CRC. In order to maintain and enhance the roles of rural and remote GPs in CRC care, appropriate guidelines and remuneration should be provided. Palliative care support might also be useful to rural and remote GPs.     

Partnering with communities to address the mental health needs of rural veterans

Purpose: Many veterans who face mental illness and live in rural areas never obtain the mental health care they need. To address these needs, it is important to reach out to community stakeholders who are likely to have frequent interactions with veterans, particularly those returning from Operations Enduring and Iraqi Freedom (OEF/OIF). Methods: Three community stakeholder groups—clergy, postsecondary educators, and criminal justice personnel—are of particular importance for OEF/OIF veterans living in rural areas and may be more likely to come into contact with rural veterans struggling with mental illness or substance abuse than the formal health care system. This article briefly describes the conceptualization, development, initial implementation, and early evaluation of a Veterans Affairs (VA) medical center‐based program designed to improve engagement in, and access to, mental health care for veterans returning to rural areas. Findings: One year since initial funding, 90 stakeholders have attended formal training workshops (criminal justice personnel = 36; educators = 31; clergy = 23). Two training formats (a 2‐hour workshop and an intensive 2.5‐day workshop) have been developed and provided to clergy in 1 rural county with another county scheduled for training. A veteran outreach initiative, which has received 32 referrals for various student services, has been established on 4 rural college campuses. A Veterans Treatment Court also has been established with 16 referrals for eligibility assessments. Conclusions: While this pilot program is in the early stages of evaluation, its success to date has encouraged program and VA clinical leadership to expand beyond the original sites.