Homeless individuals have more health complications relative to the general population, showing significantly high rates of both acute and chronic clinical conditions. Homeless adults, for instance, report numerous cases of unmet health needs for several types of conditions. Some studies had shown that about one-fourth of homeless persons did not get medical care in the past year (Nunez, Gibson, Jones, & Schinka, 2013). Comparatively, one study established that one in six sick Americans noted that there was “a time in the past 12 months when they could not get the medical care they needed” (17%) (National Public Radio, Robert Wood Johnson Foundation, & Harvard School of Public Health, 2012). Some health care disparities have been linked to low access to care in homeless persons. Such disparities also affect dental care provisions among homeless persons (Nunez et al., 2013). In fact, about 10% among homeless adults claims that dental care is among the top unmet health care needs (Nunez et al., 2013). In addition, cases of untreated dental caries were reported in 58%. A previous study by Nunez et al. (2013) demonstrated that homeless veterans, for instance, have poor oral health based on all measurement indicators, such as decayed teeth, missing teeth, and oral pain. Both poor dental health and appearance have been linked to challenges related to quality of life. Homeless adults often demonstrate improved self-perceived quality of life following dental care provision. Such outcomes, therefore, show the need for sufficient access to oral health care in homeless individuals. It is observed that Whites and some wealthy persons have higher incidences of tooth decay, but the lower income groups alongside Blacks and Hispanics have a higher prevalence of untreated dental caries in permanent teeth (Dye, Li, & Thornton-Evans, 2012). This high prevalence is largely attributed to a lack of access to dental health care services. Unfortunately, there has been more attention to the use of prevention strategies in children relative to adults in the use of fluoride products and sealants. Hence, this paper describes a health promotion program aimed to mitigate occurrence of dental caries by educating homeless people and providing treatment options to adults already afflicted but not able to access treatment.
Review of the Literature
In North America, gaining access to health care is a major challenge many homeless persons encounter (Figueiredo, Dempster, Quiñonez, & Hwang, 2016). Notably, homeless persons usually do not have regular health care sources, and they have cases of poorly treated physical and mental conditions, which may later require immediate hospitalization in emergency departments. While homeless persons visited emergency departments for health problems, their conditions could be sufficiently managed at ambulatory settings. However, emergency departments remain the most accessible for disadvantaged populations.
Costa et al. (2012) noted a decline in the incidence of dental caries in both developed and emerging countries. Notwithstanding such achievements, cases of dental caries are still high in individuals of low socioeconomic status. Thus, socioeconomic indicators have been linked to risk factors for adult dental caries (Costa et al., 2012). Furthermore, socially disadvantaged persons, such as homeless individuals, also experience disparities concerning health care in totality. In fact, small groups of such individuals have greater cases of diseases. Health risks have been identified using distinct social groups in societies based on achievements in the field of social epidemiology, although health disparities continue to increase in most settings. Consequently, such prevailing scenarios have presented new opportunities and challenges for researchers to explore how social disparities influence health care provision and outcomes. In this case, the need for empirical data for decision-making has been vital for health care improvement (Costa et al., 2012). Further, Costa et al. (2012) also pointed out that social class or socioeconomic status is critical predictors of disease occurrence. Dental caries care was characterized by less access and treatment, specifically in vulnerable families characterized by low incomes, lack of education, poor access to oral care products, poverty, and limited knowledge on oral hygiene and care (Costa et al., 2012). Consequently, vulnerable persons tend to report higher incidences and severity of dental caries (Costa et al., 2012).
One major role of Healthy People 2020 is to observe health disparities in the public, and oral health is among the observed cases. In this regard, vital sociodemographic factors for oral health disparities in the US have been identified as poverty status, race, and ethnicity (Dye et al., 2012). It is imperative to point out that children were also affected with dental caries at significantly higher rates when sociodemographic indicators were observed. For adults, Dye et al. (2012) established that the frequency of complete tooth retention was generally higher among adults aged between 45 and 64 living above the poverty level defined by the federal government relative to other adults of the same age group living below the poverty line. According to findings, between 2009 and 2010, 15% of adults aged between 65 and 74 and 22% of adults aged 75 and above were edentulous (Dye et al., 2012). Notably, adults who lived at or below the 100% of the poverty level defined by the federal government had high rates of complete tooth loss. It was as high as twice for individuals aged 65-74 (34%) relative to 13% of persons living above the poverty line. In addition, adults aged 75 and above had 24% of tooth loss relative to 21% of adults living above the poverty line. More importantly, these differences were linked to race and ethnicity status as major determinants of health status in the US.
Dental caries prevalence is high globally, and across all the regions, economic, social, and individual determinants are seen as the major causes (Costa, Vasconcelos, & Abreu, 2013). These factors, however, may be grouped as either proximal, which accounts for modifiable behaviors, such as “oral hygiene practices, dietary habits, life style and the use of oral health services” (Costa et al., 2013, p. 2401); or distal, which is associated with “socio-environmental factors and to the availability of oral health services” (Costa et al., 2013, p. 2401). Costa et al. (2013) established that high caries severity was linked to consistent visits to the dentist, use of supplementary or home remedy dental services, and a lack of advocacy to authorities for community benefits. These are some of the challenges faced by homeless individuals. Thus, it is imperative to assess diverse health care determinants, such as poverty and minimal social integration, associated with dental caries severity.
Some researchers have singled out homeless persons for oral health care issues (Seirawan, Elizondo, Nathason, & Mulligan, 2010). In fact, Seirawan et al. (2010) found out that about 58% of 1,088 homeless patients had untreated cases of dental caries. Consequently, they concluded that homeless persons were underserved with oral health care services and, therefore, were in greater need of surgical, restorative, and periodontal dental care. In this regard, community health initiatives were seen as vital for evaluating and enhancing oral health care among the underserved homeless persons (Seirawan et al., 2010).
Studies have indicated the effectiveness of oral health educational intervention. It was associated with increased knowledge, attitude, and oral health practices (Haque et al., 2016). Oral health education also led to reduced cases of untreated dental caries in adolescents in underserved rural parts of Bangladesh (Haque et al., 2016). A specific study to evaluate health promotion for homeless persons determined three themes, namely incorporating homelessness, health improving, and health engaging (Coles, Themessl-Huber, & Freeman, 2012). Coles et al. (2012) observed that the health promotion design had to engage homeless persons and the approach had to be specific, acceptable, appropriate, and possibly effective to realize the goals of intervention. Further, oral health education was associated with reduced rates of decayed teeth, enhanced eating habits, and low cases of teeth with plague in adolescents (Bica et al., 2015). Bica et al. (2015) found out that the intervention had positive effects on behavior change to advance healthier lifestyles and act as an indicator of oral health status.
Description of the Project/Plan
Goals and Objectives
Tooth decay is a serious dental problem that contributes a lot to complete or partial edentulism. The most important goal was to ensure the campaign is implemented successfully for homeless people.
At the end of the oral health educational program, there will be a 15% increase in the level of knowledge when pre-test scores and post-test scores are compared in homeless adults aged 20-64 who have mastered dental cavities, related symptoms and nutrition at Hope House Mission in Middletown, Ohio.
The educational topic Dental Caries in Adults was implemented in two distinct phases with three segments. The first phase was implemented on October 17, 2016 at Hope House Mission Men’s Center in Middletown, Ohio. In this phase, two segments on the dental caries: what are dental caries, how they are formed, and what the preventative measures are, were implemented, alongside other risk factors, signs and symptoms. There were 22 men ages 20-69. The coordinator made it mandatory for the residents to attend the class and, thus, everybody signed in. Two denture models were also passed in the class, which complemented the educational elements by providing visualization of the oral structure. One of the model showcased the healthy gums, while the other one had plaque and tooth decay. Participants were provided with nutritious snacks during the teaching process to ensure that they were engaged throughout the session. The coordinator had pointed out that they liked snacks, but snacks were provided to enhance their knowledge about foods that are good for the overall health. A pre-test was given at the start of the class followed by PowerPoint brochures on dental caries. Finally, post-tests were given at the end of the class to evaluate outcomes. Projects require clarity on “expected objectives and outcomes will be, and to identify what specific changes are expected for what specific population” (UN Women, 2012). Overall, the response by residents was overwhelming after a class session of about 50 minutes, including a question-and-answer session on the topic.
The third segment of the topic was delivered on October 28, 2016 at Hope House Mission Men’s Center and Hope House Women and Children’s center. The nutritional segment covered information on healthy nutritious food considered good for overall wellbeing, as well as foods that prevent tooth decay, such as calcium, fruit, fiber, veggies, sugarless chewing gum, green and black tea, and water with fluoride. Additionally, foods that cause dental cavities, such as starchy refined carbohydrates, fruit juices, carbonated soft drinks, and acidic foods were discussed. Participants were quite astonished to learn that is it better to drink from the tap rather than from the bottles because of the fluoride. Participants were served with vegetarian meal – kidney beans curry (Rajma) along with rice cooked with different spices. Some other healthy snacks, such as bananas, apples, oatmeal, nuts bars, and popcorns, were also provided. The session started with a pre-test, and after the content was disseminated, a post-test was given. Participants enjoyed learning new materials and raised related questions. The pre-test and post-test evaluation provided concise and effective direct evaluation that brought about reasonable dialogue to improve the learning environment (Boston University, 2013). Discussion and question-and-answer engagements made all participants active in a session that lasted about 35 minutes.
The final phase involved tallying both pre-test and post-test scores and working on the project assignment. Brochures with the topic contents were also distributed to participants, including useful information on a list of physicians, general dentists, dental surgeons, endodontists, and other oral health care providers who accept Medicaid and Medicare. Each segment covered in the educational program was used to assess participant’s increase in knowledge from the education session and if indeed, learning had occurred. There were about 20 participants in each class. The first segment focused on dental cavities with the pre-test score of 69% while the post-test score increased to 94%. The second segment focused on signs and symptoms of dental cavities where pre-test score was 73% and the post-test score was 91%. Finally, the third segment focused on the nutritional component in which the pre-test score was 74% and the post-test score ended with 95%.
Overall, it was delightful to see the increased scores on the post-test, which demonstrated that learning had indeed occurred among homeless individuals.
This project was successfully implemented in partnership with the Hope House Mission in Middletown, Ohio. The coordinator was extremely helpful. Adult homeless persons were the major stakeholders in this project. I partnered with Dr. Sarabjit Thind to distribute the free dental kits to the individuals. I contacted the healthcare providers to tell them about the project and they should look forward to follow up visits from the shelter.
The major resources deployed for this project implementation were financial, time, learning materials, intellectual capital, and facilities used to conduct lectures.
The project implementer used personal funds and other resources to implement this project. Thus, no external sources of funds were used.
Given the financial constraint, budgeting was restricted to only vital items for the project.
|Table 1 |
|Brochures||$1.10 each for 30 participants||$33|
|Snacks and other foodstuffs||For all days were $66.00, $57.00, and $63.00||$186.00|
|Transport and other facilitation costs||For all days were $5.00, $6.00, and $10.00||$21.00|
Data were analyzed using frequencies and percentage to determine changes in knowledge following implementation of the project, Dental Caries in Adult.
|Table 2 |
|Segments||Pre-test scores||Post-test scores||Percentage change|
|Signs and symptoms of dental cavities||73%||91%||18%|
Pre-test and post-test program scores were analyzed and compared, and it was observed that there was a significant percentage increment in dental caries in adults, oral health care knowledge, signs and symptoms of dental caries, and nutritional knowledge. In addition, percentage scores on oral hygiene status of homeless persons and specific information on where to find oral health care increased after the project implementation. Overall, results indicated positive outcomes on homeless persons, and the project was able to affect their lives positively.
Evaluation accounts for process and outcome of the dental caries in adult project implementation. Program evaluation is a systematic method for collecting, analyzing, and using information to answer basic questions about a program. It is a valuable tool to strengthen the quality of program and improve the outcomes. It helps in determining the effectiveness of a program and, therefore, pre-test and post-test were developed to measure the outcomes. There were three segments on the dental caries and each had its own pre-test and post-test. Impact evaluation was used at the end of the interventional educational program to determine the degree to which the program met its main goal overall rates of knowledge acquisition for the three segments. Based on the results, the project implementation had positive effects on the targeted homeless persons at Hope House Mission in Middletown, OH.
This project implementation stage provided opportunities for further learning and seeking for novel ways to advance public knowledge on oral health care. It is necessary to identify current needs of a community and then develop processes of planning, use of evidence-based research to back up the topic, implementation, and finally the evaluation of the project. Each phase has its own importance and is critical to the research project. Of course, project implementation is not simple because the initial intended project strategy was not possible to implement and was subsequently discarded. It required the use of social media and radio to raise awareness of dental caries in adults, but the plan was a failure and an alternative had to be implemented. Projects require collaboration among community partners to address needs of the public. After going through the implementation phase, one becomes confident to carry out another public health project. Moreover, practicum lessons help in developing interpersonal skills required to execute a public health project. While the process is not easy, once the project is completed and positive outcomes are achieved, it is totally worth it. Education is empowering and there is so much that can be done for a community. Education intervention can address current needs of the vulnerable population, such as personal hygiene, vision, STD’s, hepatitis C among other health conditions.
Individuals experiencing homelessness carry a high burden of medical and behavioral health illness. They often struggle with balancing the daily needs of shelter, food, and safety with management of health and health care needs. They also frequently lack health insurance or access to continuity of care. This mix of factors often leads to a high usage pattern of the emergency department system. Multiple studies have documented high usage patterns among homeless individuals and the resultant high costs (Bharel, 2016). Public health must play a key role in data collection and analytics and advancing the connection between the health care system and community-based services.
This project demonstrated the importance of providing educational programs to people who are underserved with the current health care system. Perhaps one of the major challenges encountered by the homeless persons is that they and the challenges impacting them are always ignored. In most instances, the approach of the public is that the homeless persons must be responsible for their situation and so they should seek for solutions to their own problems. Oral health challenge among homeless persons is among the often-ignored problems. Consequently, the problem has become extremely complicated. This project demonstrates that simple approach, such as creating public awareness through educational programs, can significantly improve dental caries among the target population. Thus, it has practical implication for policymakers and health care providers.
Bharel, M. (2016). Emergency care for homeless patients: A window into the health needs of vulnerable populations. American Journal of Public Health, 106(5), 784-5. Web.
Bica, I., Cunha, M., Reis, M., Costa, P., Costa, J., & Albuquerque, C. (2015). Educational intervention for oral health. Procedia – Social and Behavioral Sciences, 171, 613-619. Web.
Boston University. (2013). Choosing the right assessment method: Pre-test/post-test evaluation. Web.
Coles, E., Themessl-Huber, M., & Freeman, R. (2012). Investigating community-based health and health promotion for homeless people: a mixed methods review. Health Education Research, 27(4), 624-644. Web.
Costa, S. M., Martins, C. C., de Lourdes, C. B., Zina, L. G., Paiva, S. M., Pordeus, I. A., & Abreu, M. H. (2012). A systematic review of socioeconomic indicators and dental caries in adults. International Journal of Environmental Research and Public Health, 9(10), 3540–3574. Web.
Costa, S. M., Vasconcelos, M., & Abreu, M. H. (2013). High dental caries among adults aged 35 to 44 years: Case-control study of distal and proximal factors. International Journal of Environmental Research and Public Health, 10(6), 2401–2411. Web.
Dye, B. A., Li, X., & Thornton-Evans, G. (2012). Oral health disparities as determined by selected Healthy People 2020 oral health objectives for the United States, 2009–2010. National Center for Health Statistics, (104), 1-8.
Figueiredo, R., Dempster, L., Quiñonez, C., & Hwang, S. W. (2016). Emergency department use for dental problems among homeless individuals: A population-based cohort study. Journal of Health Care for the Poor and Underserved, 27(2), 860–868. Web.
Haque, S. E., Rahman, M., Itsuko, K., Mutahara, M., Kayako, S., Tsutsumi, A.,… Mostofa, G. (2016). Effect of a school-based oral health education in preventing untreated dental caries and increasing knowledge, attitude, and practices among adolescents in Bangladesh. BMC Oral Health, 16, 44. Web.
National Public Radio, Robert Wood Johnson Foundation, & Harvard School of Public Health. (2012). Sick in America. Web.
Nunez, E., Gibson, G., Jones, J. A., & Schinka, J. A. (2013). Evaluating the impact of dental care on housing intervention program outcomes among homeless veterans. American Journal of Public Health, 103(Suppl 2), S368–S373. Web.
Seirawan, H., Elizondo, L. K., Nathason, N., & Mulligan, R. (2010). The oral health conditions of the homeless in downtown Los Angeles. Journal of the California Dental Association, 38(9), 681-8.
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Pre-Test: Dental Cavities: Nutrition
- Diet is important in maintaining good dental health.
- True. Diet plays a role in the health of teeth and gums.
- False. It doesn’t really matter what you eat.
- You should drink the bottled water.
- Chewing ice is good for teeth?
- Citrus foods are good for tooth enamel?
- Drinking carbonated drinks and juices are good for oral health?
Pre-Test and Post-test: Dental Cavities
- What are dental cavities?
- Hole in teeth
- Food particles
- What is another name for dental cavities?
- Tooth decay
- What is plaque?
- Food particles stuck between teeth
- The sticky layer of bacteria in the mouth that coat the teeth
- Gum disease
- What directly causes dental decay?
- Eating foods that break down easily into sugars
- The acid produced by bacteria and sugars in the mouth
- How can you prevent tooth decay?
- Antibacterial Rinses
- Decreased fermentable carbohydrates
- Increases saliva flow
- All of the above
- Is it possible to transmit oral bacteria by sharing the same spoon between the parents or caregiver?
- What is abscess?
- A pocket of pus that’s caused by a bacterial infection
- Dental caries is preventable?
- What factors are involved in the formation of caries?
- All of the above
- Dental cavities usually cause pain?
Pre-test and Post-Test: Dental Cavities Signs and Symptoms
- Is tobacco and drugs bad for teeth and gums?
- You should brush your teeth two times a day with a fluoridated paste?
- A good flow of saliva is necessary to control tooth decay?
- What are the symptoms of tooth decay?
- Tooth sensitivity
- Gray, brown or black spots appearing on your teeth
- Bad bread
- All of the above
- You can outgrow tooth decay?
- People should floss once a week?
- Drugs and tobacco causes no harm to your teeth?
- Chewing tobacco and drugs can make your teeth fall out?
- Chewing tobacco is the best way to quit cigarettes?
- Sensitivity means you have tooth decay/cavities?
Oral Health Brochure
- Dental Cavities are holes or structural damage in teeth.
- It is an infectious, transmissible disease because bacteria that causes cavities can be transmitted
- It results in tooth decay, process that occurs over time
Signs and Symptoms
- Tooth sensitivity
- Mild to sharp pain when eating or drinking something sweet, hold or cold
- Visible holes or pits in your teeth
- Pain when you bite down
- Brown, black or white staining on any surface of a tooth
How to prevent dental cavities?
- Brush with fluoridate toothpaste after eating or drinking
- Rinse mouth with fluoride
- Consider dental sealants
- Drink tap water
- Avoid frequent snacking or sipping
- Eat tooth-healthy foods
- Avoid tobacco, cigarettes, and drugs
- Brush twice a day and replace your toothbrush every 3 months
- Calcium: Milk, yogurt, cheese, broccoli, Brazil nuts, canned fish with bones, almonds
- Fruit, fiber, and veggies: dried fruits such as raisins, dates, fig, bananas, apples, strawberries, Brussel sprouts, peas, peanuts, brain, whole grain cereals, pasta.