Increasing Capacity to Inform Oral Health Policy

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Presentation by the Office of Canada's Chief Dental Officer

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  • -available electronically; -free to interrupt; -time at end for discussion. -Appreciate that new members here so will do a quick backgrounder for them.
  • This table reflects only direct costs (the value of goods and services for which payment were made, and measures used in treatment, care, and rehabilitation). Indirect costs (the value of economic output lost due to illness) are not included here. The direct costs for dental disorders in 1993 ranked third, after cardiovascular diseases and mental disorders. However, its rank moved to second place after accounting for surface costs from mental disorders in 1998.
  • Web – where we fit in.
  • Public health Count Dentists, Dental Hygienists, Dental Assistants, Dental Therapists, others Health Promotion/ Disease Prevention / Health Protection All would be (Community/Targeted);
  • Bangladesh population density ->6.4 B population into Canada. Nunavut 1/70 sq. Km.
  • CHMS covers approximately 97% of Canadians Misses First nations on Reserve Residents of Institutions Canadian Forces full time members Since most of the Inuit do not live in areas with 10,000 within 100 km radius they were missed Yellowknife was the only North of 60 community to qualify National Needs Assessment to: Determine burden of illness Identify inequalities Inform policies Assess current delivery systems Determine health promotion strategies
  • This is difference between a treatment plan and disease surveillance
  • Pop = population
  • I will talk more later about indexes during the section on examiner calibration
  • The development of the CHMS survey was recognized to be a complex undertaking that needed to consider broad issues. The CHMS therefore established a Steering Committee that brought together expertise, both national and international, from a wide variety of areas to determine the specific health measures to be included in the CHMS. The Steering Committee was tasked with considering the current available health information and identifying the health issues and indicators that would be included in the CHMS.
  • Once the health issues to be studied were identified, subject matter specialists were brought together to consider these issues which would determine: which measurements would be utilized how the measurement would be taken (indices training requirements for each measures best equipment, tools etc to be utilized Blood pressure Resting blood pressure Would it be taken manually or using automated BP machines How many times would the BP be taken – once twice, three time? What is the resting period between BP Should the examiner talk to the respondent between measurements What will the rate be measured against? What is normal?
  • US – Lead; Australia – Diabetes. Canada – Health Information Roadmap Initiative, Budget 2003. (Dental Confirmed 2005). #1 Priority OCDO #1 Priority FPTDD Federal “Here to help”.
  • Treating heart disease is costly to the health care system. If we make assumptiongs about the number of individuals requiring by-pass surgery each year for example: To stay the same, means the same number of cases each year We know the baby boomer population is aging and the number within the population group is larger than the generation before Will they have the same number proportion of cases? If they do the real number will go up 10% of 1000 = 100 cases each year 10% of 2000 = 200 cases per year 20% of 2000 = 400 cases per year
  • Why is knowing the health of Canadians so important? The objective here is to establish a baseline on the health of the average Canadian Interview questions will provide self reported information: context Physical measures are identified: Actually measuring physical attributes We’ll have the ability to compare actual physical measures to self reported questions. This bit is important as it we will be able to have a correction factor that can be applied to other existing surveys
  • Three (3) Phases: 1-Planning (2003-2007) Survey Development -questionnaire -Clinical Instruments -Consents -Ethics -Privacy Commissioner -In home visits -Communications -Data processing 2-Data Collection (2007-2009) Operations -Interviewers -Methodology -Computer application -Clinic Operations (trailers etc.) 3-Outputs (2008-2011) -Information dissemination -Research community
  • The survey design is complex and multi-staged Start with Canada as whole Uses census subdivisions as basis Defined sampling frame Population of 10,000 minimum (Labour Force Survey) Urban area within 50km; Rural areas within 100km Originally 257 sites representing 97% of population; reduced to 30 and finally reduced to 15 sites Objective was to ensure that there were enough children in the survey Identified household by the age of residents Whenever possible within the site a household is selected based on one child (aged 6-12) and one adult Then randomly selected the respondent 1 respondent per household; 2 if a child aged 6-12 was present Household interview then clinic visit
  • 7 days a week Hours 7 – 3 and 7 – 9 days Overlapping shifts Dentists are actually Captains from the Canadian Forces (CF) Unique partnership between HC/STC and CF Anyone working for the survey, needs to be either a STC employee or deemed to be STC employee. CF are sworn in. I was sworn in as a STC employee as I wanted to observe dentally related processes All the survey staff receive initial and ongoing training: Background on Statistics Canada and their responsibilities as a STC employee – Protection of personal information is paramount Training in safety measures – CPR first aid Training on specific tests and measures How to use the computerized data collection application Interviewers are experienced STC employees but required specific training on asking health questions some of which can be very sensitive
  • MOU with DND; 2 dentists/team; 7 days/week (3 with 2 + 2); Lifeline retrofitting -> “-40 ◦ C”, 4 in total Advanced arrangements team: Parking lots University Hotel Hospital (Calgary problems) Walmart Order: Screen (smoke–cotinine; eat-fasting glucose, have medications changed) B.P. Urine Blood 2 super-rooms: sit, reach, curl, dynamometer, steps. 1 oral room Never done in cold in the US.
  • Need to quantify the problem; Last national baseline epidemiological information 1970 – 1972; National Needs Assessment to: Quantify the burden of illness; Identify inequalities; Assess current oral health delivery systems; Form policies.
  • 46 questionnaire modules containing 722 questions Approximately 50 physical measures variables Over 120 biospecimen analytes About a dozen Environment Canada weather / pollution indicators Potential linkage to health records Household questionaire link Look at: 45 minute interview – oral health is about 3 minutes Interview questions must relate to the clinical questions Limitations of self-report data: Social desirability trends. (PEI Height/Weight Studies) Respondent recall ability Reporting bias Knowledge of conditions (Australian Diabetes Studies, STI’s Calgary) Learned from CCHS (Mental Health) as interviewers trained well (Calgary example) 4 sensitive areas: Drugs Sexual behaviour Pregnancy (alcohol) Income (hardest to obtain) Face to face works, parent out (mother…. Cross Tabs: Income – Oral Health Status Tobacco/alcohol – Perio Urine Inorganic Hg – Amalgams Preventive practices Health Human Resources Oral Health – we’ll go into the oral health questions in a few moments
  • Consent is explained during the household interview and reconfirmed at the time of the clinic visit Consent can be revoked at any time during the process. General consent for adults Proxy consent for children aged 6 -12 Children may decline Reconsent for children for biological material De-identified data sharing with partners Data linking with provincial health programs
  • This list of topics was generated through multiple consultations with the PHAC, Health Canada and Statistics Canada. A much larger list was pilot tested to create this final list. Any modules that were difficult to ask (i.e. too sensitive of material- social networks) or were too long or too complicated to ask were either edited or removed.
  • Look at: Income, Chronic, Soft Drink consumption, Medications, Smoke etc. Limitations of self-report data: Social desirability trends. (PEI Height/Weight Studies) Respondent recall ability Reporting bias Knowledge of conditions (Australian Diabetes Studies, STI’s Calgary) Learned from CCHS (Mental Health) as interviewers trained well (Calgary example) 4 sensitive areas: Drugs Sexual behaviour Pregnancy (alcohol) Income (hardest to obtain) Face to face works, parent out (mother…. Cross Tabs: Income – Oral Health Status Tobacco/alcohol – Perio Urine Inorganic Hg – Amalgams Preventive practices Health Human Resources Oral Health: Perceived status Appearance Treatment needs Pain Bad Breath Time for dental care Dental visits Insurance
  • NHANES- National Health and Nutrition Examination Survey
  • For example, a respondent questioned what a Stimudent was and if that counted toward flossing if they used one everyday. As a result, there was a note added to the interviewer manual that Stimudent is a type of toothpick and does not qualify as flossing. The interview guide was developed as an adjunct to the household survey to help the interviewer if a question was asked to which they did not know the answer.
  • This slide has a list of the health issues that will be studied under the CHMS. Additionally, the interrelationship between the issues can also be investigated. For example, oral health could be assessed in relationship to diabetes where we already know this is relationship The relationship between oral health and heart disease could be investigated .
  • Blood: Cholesterol, glucose etc, cotinine. Urine: Diabetes, kidney function, (HPV’s off).
  • As research has evolved and continued, over the last 20 years it has become very clear that we cannot have good general health without good oral health. This list outlines the common areas of linkage but the obvious connections of periodontal disease and diabetes, aspiration pneunomia and dental plaque bacteria and viruses and problems associated with oral cancer are now well established in the scientific literature.
  • Oral health can have a major impact on an individuals ability to communicate, their self-esteem, employability, and social contacts (impact of halitosis)
  • Approximately 20% may be problematic; Importance of oral health: Caries ECC Perio Growth & Development (cleft lip/cleft palate after Down’s) Xerostomia Viral infections Neoplasms Local impact on life (eating, chewing, pain, social acceptability, aesthetics, neuromuscular component) Linkages: now accepted (Diabetes, Pneumonias, Cancers) Work continues (Cardiovascular, Adverse pregnancy etc).
  • Seniors: Teeth / feet / bowels. Risk Factor: Nutrition, Tobacco, Alcohol.
  • This is an important step for guiding the development of the survey, implementation through to the analysis. The steering committee is now involved in advising on the 2010 Oral Health Report Consideration Bring together researchers, regulators, professional and government officials from the outset. This is an important step for guiding the development of the survey, the implementation through to the analysis. Dr. Jean-Marc Brodeur- Professeur , Département de médecine sociale et préventive Dr. James L Leake - Professor Emeritus, Faculty of Dentistry, University of Toronto Dr. Patricia A Main - Chair, Federal Dental Care Advisory Committee Dr. Euan Swan - Manager Dental Programs, Canadian Dental Association Dr. Gordon Thompson - Canadian Dental Regulatory Authorities Federation Dr. Sandy Bennett - Chair Federal/Provincial/Territorial Dental Working Group Ms. Andrea Richard - Dental Hygienist (On Executive of CAPHD) Colonel SA Becker - Director Dental Services, Canadian Forces Peter V. Cooney (Chair) OCDO Harry Ames OCDO Amanda Gillis OCDO
  • Determining the objectives of the oral health component Collecting and reviewing oral health surveys from other countries i.e. National Health and Nutrition Examination Survey (NHANES)/ Australia/ World Health Organization (WHO) Developing the household, the clinical survey questions and the protocol manual Choosing dental instruments according to the indices in the clinical survey Providing ongoing advice to the Office of the Chief Dental Officer throughout the survey collection period Act as peer review group for the Oral Health Report Dr. Jean-Marc Brodeur- Professeur , Département de médecine sociale et préventive Dr. James L Leake - Professor Emeritus, Faculty of Dentistry, University of Toronto Dr. Patricia A Main - Chair, Federal Dental Care Advisory Committee Dr. Euan Swan - Manager Dental Programs, Canadian Dental Association Dr. Gordon Thompson - Canadian Dental Regulatory Authorities Federation Dr. Sandy Bennett - Chair Federal/Provincial/Territorial Dental Working Group Ms. Andrea Richard - Dental Hygienist (On Executive of CAPHD) Colonel SA Becker - Director Dental Services, Canadian Forces Peter V. Cooney (Chair) OCDO Harry Ames OCDO Amanda Gillis OCDO
  • There are 15 questions in total Taking about 5 minutes to complete See section 2 for the oral health household survey Complete household Areas Health Status: General Health, Height and Weight, Weight Change, Health Utility Index, Chronic Conditions, Family Medical History, Oral Health Nutrition and Food Consumption Fruit and Vegetable, Meat and Fish, Dietary Fat, Salt and Other Food, Water and Soft Drink, Milk Medication Use Medications, Other Health Products and Herbal Remedies Health Behaviours Physical Activities, Sedentary Activities, Smoking, Alcohol Use, Illicit Drugs, Sexual Behaviour, Sleep Childhood Development Pregnancy, Birth and Breastfeeding Information Environmental Factors Exposure to Second-Hand Smoke, Housing Characteristics, Exposure to Toxic Chemicals, Sun exposure Socio-Economic Information Socio-Demographic Characteristics, Education, Labour Force Activity, Income
  • Tooth Surface Index of Fluorosis ( TSIF ).
  • Block testing with fictional cases Pretest with 10 per age group - summer 2006 (time estimates, suitability of survey, equipment (including computer application). Now into the calibration over next few months with inter and intra examiner reliability. Current bisphenol A issues. Cross Tabs: -Insurance -Tobacco -Health Human Resources -Research Needs
  • An adjustment was made max value in the amalgam count question- needed to include count on wisdom teeth in the question. Amalgam question Max was 5X the number of teeth in chart with a code of 12. eg. 4 teeth with a code of 12 yields a maximum of 20 But the 8’s could have amalgam so could exceed the original count.
  • Amalgam count and wisdom teeth Recession Attachment Loss
  • An OCDO staff person has been available by phone/ email during the hours of the MEC to address any issues. This led to having one recorder becoming the head recorder to ensure all were kept in the loop as changes developed.
  • 2 monitors – 1 for the dental recorder and one for the dentist so that they both can see the entry screen simutaneously
  • During February and March 2007, Statistics Canada held a one month dress rehearsal on the entire CHMS. All seven of the Canadian Forces dentists and the two backup dentists/trainers participated in the dress rehearsal. This dress rehearsal was designed to ensure that the timing and the flow of both the respondents and the information worked and provided the CF dentists and clinic coordinators (dental recorders) an opportunity to work together.
  • I will discuss each of these briefly but these items were common to both the First Nations and Inuit National versus regional or community level data Collecting regional or community level data would require a massive financial and logistical undertaking FNOHS data will be national level for on-reserve only IOHS data will be national Survey timing and completion Completion should be closely timed to completion of CHMS data collection (March 31/09) Timing is very tight but doable with HC regions help IOHS will likely get underway in April/08 FNOHS will likely get underway in Sept/08 Data comparability to CHMS data Both surveys will utilize the CHMS clinical exam as is and the oral health interview questions as the basis of their questionnaire Inclusion of children under the age of 6 Will Include children under the age of 6 being proposed as 3 – 5 years olds - Tailor approach
  • Staff concerns about sterilizer new to them noises, residues, corrosion of instruments, spore testing OCDO staff member available by telephone at all times the MEC was operating. It alienated staff concerns to know if any question just call. Usually it was to just confirm that everything was ok and they had not destroyed the sterilizer.
  • Obtaining accurate lists of respondents Use existing lists if rules allow – rules may not allow you to see the full list but may allow those who have the authority to select respondents off the list for you Make your own list – door to door name collection etc. Advertisements asking to call and put name on list Attracting respondents participation Incentives Convenience Schools Daycares Elder facilities Stores North Mart
  • Aim for an “Oral Health in Canada” document in 2009 (10). Other areas have published similar documents US Surgeon General Australia Analysis Planning underway Experienced researcher to assist with writing Federal Dental Care Advisory Committee to act as peer review group Public friendly document and technical report – highlight best practices
  • CDA well positioned as having solved 80% of Canadians oral health issues and now has the opportunity to facilitate/promote solutions for the access to the same oral health standards for the remaining 20%
  • Dr. Patricia Main, Chairperson Dr. Howard Tenenbaum , Vice-Chair - University of Toronto Faculty of Dentistry, Periodontology Dr. William A. MacInnis - Nova Scotia Provincial Dental Board Ms. Lynda McKeown , RDH, HBA, MA Mr. Tony Sarrapuchiello - Denturist Association of Canada Dr. George H. Sweetnam – A Past President of the CDA Dr. Michael l. MacEntee - Professor of Prosthodontics and Dental Geriatrics, ELDERS Research Group, Department of Oral Health Sciences, Faculty of Dentistry, University of British Columbia MANDATE The mandate of the FDCAC is to advise the Office of the Chief Dental Officer and the federal departments on oral health policy, on best practices and evidence based oral health as well as on specific clinical issues, including current issues, new technologies and procedures, complimentary issues that will impact on the oral and dental health and needs of their clients. The Committee provides current advice on oral health as it impacts on general health and on dental health, on program delivery as well as on third party insurance and dental benefits in order that the departments can improve and maintain the oral and general health and well-being of their clients. RESPONSIBILITIES The FDCAC: will establish and maintain evidence based and best practice criteria for consideration by the Office of the Chief Dental Officer (OCDO) and the Departments, that guide the inclusion and the exclusion of dental benefits, provided through the federal programs; will advise on current and emerging oral health issues either identified by the Committee, by the Office of the Chief Dental Officer (OCDO) or by the federal departments; will advise on the trends, information and statistics on access to care, needs and utilization presented in reports for the purpose of policy and program development and evaluation will advise on the program delivery, including establishment of federal dental facilities and on the purchase of dental services and supply will advise on the need for and implementation of educational programs for dental providers and clients will conduct or ensure the conduct of reports/ studies necessary to the provision of advice in areas of oral health that are of immediate concern or policy development. will as needed, recommend appropriate funding for studies of the client populations that could lead to changes and improvements in oral healthcare delivery
  • We do not want the Oral Health report card to overwhelm the importance of the sub group reports so are planning separate publication dates. and surveyed seniors oral health living in community and in Long term Care facilities. Note dates of completion Inuit should have been completed initially Dec 31, 2008 delayed to March 31, 2009 and completed June 15 2009 First Nation Survey Dec 31, 2008 March 31, 2009 June 30, 2009 Currently set to take place fall 2009 with first site scheduled for September 14 (8 sites to complete) completion date to be October 31, 2009
  • For our Inuit and First Nation Surveys we have had 4 calibrations and 11 examiners. Calibration for seniors survey Homeless survey BC immigrant survey – hygienists and therapists
  • Does your dog bite no you get bitten not my dog
  • Not all item are possible to analyze using statistics. Bleeding changes, debris reduces etc.
  • Increasing Capacity to Inform Oral Health Policy

    1. 1. Office of the Chief Dental Officer Increasing Capacity to Inform Oral Health Policy The National Perspective - Canada Health Measures Survey October 21-22, 2009
    2. 2. Objectives <ul><li>What is the Office of the Chief Dental Officer </li></ul><ul><li>Briefly discuss Health Canada’s priorities regarding oral health policy. </li></ul><ul><li>Review of Canadian Health Measures Survey </li></ul><ul><ul><li>Inuit Oral Health Survey </li></ul></ul><ul><ul><li>First Nation Oral Health Survey </li></ul></ul><ul><li>Calibration of Examiners </li></ul><ul><li>Oral health Report Card 2010 </li></ul>
    3. 3. Background <ul><ul><li>Dental disease is the most common chronic disease in children and adolescents in North America. </li></ul></ul><ul><ul><li>It is five times more common than asthma . </li></ul></ul><ul><ul><li>In Canada we spend $10 billion dollars annually on oral health care. </li></ul></ul><ul><ul><li>Dental disease is one of the main reasons for preschool children to receive a general anesthetic. </li></ul></ul>
    4. 4. Direct Costs of Illness in Canada by Diagnostic Category (1993 vs. 1998) (CIHI,1999; Leake & Kalyani, 2001)
    5. 5. Creation of Canada’s Office of the Chief Dental Officer (OCDO) <ul><li>Advocating for a Chief Dental Officer (CDO); </li></ul><ul><ul><li>Over 160 countries in World Dental Federation had a CDO; </li></ul></ul><ul><li>In October 2004, Office of the Chief Dental Officer created; </li></ul><ul><li>Announced by Health Canada in January 2005; </li></ul><ul><li>A five (5) year Strategic Plan reviewed by the Departmental Executive Committee (DEC) annually; </li></ul>
    6. 6. Health Canada - Branches and Agencies http://hc-sc.gc.ca/ahc-asc/branch-dirgen/index_e.html
    7. 7. Mandate <ul><li>Provide evidence-based oral health perspectives on a wide range of health policy and program development issues </li></ul><ul><li>Provide expert oral health advice, consultation and information </li></ul><ul><li>Integrate oral health promotion with general health (wellness) initiatives </li></ul><ul><li>Assist in gathering epidemiological information for program planning on federal/provincial/community levels and establish priorities for research </li></ul><ul><li>Develop integrated collaborative approaches to preventing and controlling oral and associated diseases </li></ul><ul><li>Provide a point of contact/liaison with professional associations, provinces, academic institutions, and other non-government organizations on oral health issues </li></ul><ul><li>The Chief Dental Officer (CDO) reports to the Assistant Deputy Minister of the First Nations and Inuit </li></ul><ul><li>Health Branch. Because the activities of the office are directed at the Canadian population, the CDO </li></ul><ul><li>also has a functional responsibility to provide advice directly to the Deputy Minister of Health Canada. </li></ul><ul><li>Office web site: www.healthcanada.gc.ca/ocdo </li></ul><ul><li>                    www.santecanada.gc.ca/bdc </li></ul>
    8. 8. Horizontal Linkages -Other Federal Departments -Federal Committees External Linkages -National Associations and Boards. (NGO’s) -Provincial /Territorial Governments -Teaching Institutions -International Organizations <ul><li>Health Canada Internal Linkages </li></ul><ul><li>Health Canada Branches </li></ul><ul><li>Regions </li></ul>Functional Relationship Reports to Office of the Chief Dental Officer (OCDO) Deputy Minister Health Canada Assistant Deputy Minister FNIHB Dr. Peter Cooney Chief Dental Officer Valerie Malazdrewicz Senior Policy and Integration Advisor Amanda Gillis Chantal Rochon Executive Lyne Y Chartrand Administrative Dr. Harry Ames Assistant Chief Student Position Policy Advisor Assistant Assistant Dental Officer Lisette Dufour Survey Coordinator Lisette Dufour Survey Coordinator
    9. 9. Priority Areas <ul><li>1. Needs Assessment </li></ul><ul><li>2. Identify Information Gaps </li></ul><ul><ul><li>Fluoridation status in Canada </li></ul></ul><ul><ul><li>Public Health Count </li></ul></ul><ul><ul><li>Provincial Plan Coverage </li></ul></ul><ul><ul><li>Fluoride policies (Water, Toothpaste) </li></ul></ul><ul><ul><li>Support for dental health services research </li></ul></ul><ul><ul><ul><li>Universities, Canadian Institute of Health Research, Knowledge Transfer </li></ul></ul></ul>
    10. 10. Priority Areas continued <ul><li>3. Health Promotion/ </li></ul><ul><li> Disease Prevention / </li></ul><ul><li> Health Protection </li></ul><ul><li>4. Emergency Preparedness </li></ul><ul><li>and Response, Forensics </li></ul>Dr. Catherine Poh: BC Oral Cancer Prevention Program, Vancouver Janet Gray, Technical Consultant/DHE, Population Health Unit, LaRonge, Saskatchewan
    11. 11. Population of Canada Compared to other countries Sri Lanka 20M India 1,080.3M Bangladesh 144.3M Nigeria 128.8M Turkey 69.7M Costa Rica 4M Spain 40.3M France 60.7M Germany 82.4M United Kingdom 60.4M Trinidad & Tobago 1.1M Thailand 65.4M Uganda 27.3M Jamaica 2.7M Netherlands 16.4M Dominican Republic 9M Haiti 8.14M Japan 127.4M Vietnam 85.5M Italy 58.1M Greece 10.7M Cuba 11.3M South Korea 48.4M Ireland 4M Taiwan 22.9M Canada Population 31.9 million Other Countries Total Population 2.2 billion
    12. 12. Priority #1 – Needs Assessment <ul><li>It has been over 35 years since the last oral health clinical survey was carried out in Canada. As such there is a gap in our understanding on the oral health status of Canadians. The following surveys will fill this gap: </li></ul><ul><li>1. Canadian Health Measures Survey (CHMS) </li></ul><ul><li>This survey is led by Statistics Canada and the results will highlight the oral health status of the general Canadian population. </li></ul><ul><li>2. First Nations and Inuit Health Oral Health Status </li></ul><ul><li>This survey is being carried out with First Nations and Inuit organizations using the same oral health module protocols as the CHMS and will highlight the oral health status of First Nations and Inuit. </li></ul><ul><li>3. Oral Health Status of Homeless in Toronto </li></ul><ul><li>This survey is being carried out with the University of Toronto in partnership with George Brown College. It will us the same protocols as the CHMS and will highlight the oral health status of homeless in Toronto. </li></ul><ul><li>4. Senior’s Oral Health in Nova Scotia </li></ul><ul><li>This survey is being carried out by Dalhousie University using the same protocols as the CHMS and will highlight the oral health status of seniors in Nova Scotia. </li></ul>
    13. 13. Measurement of Oral Disease <ul><li>We use indices: </li></ul><ul><ul><li>An index is a numerical expression which gives a group’s relative position on a graded scale with a defined upper and lower limit. </li></ul></ul><ul><ul><li>Similar to a ruler, it is a standardised method of measurement which allows comparisons to be drawn with others measured with the same index. </li></ul></ul><ul><ul><li>Measure a stage of disease not absolute presence or absence. </li></ul></ul>
    14. 14. Prevalence <ul><li>Prevalence describes a group at a certain point in time. </li></ul><ul><li>Similar to a snapshot . </li></ul><ul><li>The prevalence of a disease is the number of cases in a defined population at a particular point in time. </li></ul><ul><li>It is often expressed as a rate -x per 1000 pop. </li></ul>
    15. 15. Uses of a Prevalence Study <ul><li>Planning </li></ul><ul><li>Targeting </li></ul><ul><li>Monitoring </li></ul><ul><li>Comparing </li></ul><ul><ul><li>International </li></ul></ul><ul><ul><li>Regional </li></ul></ul>
    16. 16. CHMS Steering Committee <ul><li>Health Canada </li></ul><ul><li>Public Health Agency of Canada </li></ul><ul><li>Expert Advisory Committee </li></ul><ul><li>National Health and Nutrition Examination Survey (NHANES) USA </li></ul><ul><li>Physician Advisory Committee </li></ul><ul><li>Research Ethics Board </li></ul><ul><li>Stakeholders Research Agencies </li></ul><ul><li>Quality Assurance Advisory Committee </li></ul><ul><li>Privacy Commissioners </li></ul><ul><li>Lab Committee </li></ul>
    17. 17. Considerations <ul><li>Subject matter specialists addressed: </li></ul><ul><li>Questions to be asked clinically/self report section </li></ul><ul><li>Standardized measurements and protocols </li></ul><ul><li>Training requirements & operation manuals </li></ul><ul><li>Standardized equipment & tools </li></ul><ul><li>Analysis </li></ul>
    18. 18. OCDO Priority #1 (Needs Assessment) CHMS Objectives <ul><li>Estimate the numbers of individuals in Canada with selected health conditions, characteristics, exposures </li></ul><ul><li>Estimate the distribution and distributional patterns of selected diseases, risk factors and protective characteristics </li></ul><ul><li>Monitor trends based on available historical data </li></ul><ul><li>Ascertain relationships among risk factors, protection practices, and health status </li></ul><ul><li>Explore emerging public health issues </li></ul><ul><li>Determine validity of self / proxy data </li></ul>http://www.statcan.ca/english/concepts/hs/measures.htm
    19. 19. Why do we need to know the health status of Canadians? <ul><li>Disease burden on the health care system </li></ul><ul><li>Identify diseases with common risk factors </li></ul><ul><li>Establish public health approaches </li></ul><ul><li>Targeting resources/initiatives </li></ul><ul><li>Resource management </li></ul>
    20. 20. <ul><li>Two components </li></ul><ul><ul><li>Self reported or household interview </li></ul></ul><ul><ul><li>Clinical measures </li></ul></ul><ul><li>Mobile survey- 2 sets of 2 trailers </li></ul><ul><li>1 collection team (various team members) </li></ul><ul><li>Department of National Defence linkages </li></ul>CHMS Overview
    21. 21. CHMS Design <ul><li>Sample size: 5,000-6,000 </li></ul><ul><li>5 Age / Sex groups: </li></ul><ul><ul><li>6-11, 12-19, 20-39, 40-59, 60-79 </li></ul></ul><ul><li>2 year collection </li></ul><ul><li>15 sites (350 to 375 per site) </li></ul><ul><li>1 collection team (various team members) </li></ul><ul><li>Department of National Defence linkages </li></ul>http://www.statcan.ca/english/concepts/hs/measures.htm#3
    22. 22. Selecting the Respondent Select sampling frame Select site Select household Select person in the household Household Interview Clinic visit http://www.statcan.ca/english/freepub/82-003-/SIE/2007000/article/10363-en.pdf
    23. 23. Current Status of the CHMS <ul><li>- Clarington, ON </li></ul><ul><li>-Montreal South, QC </li></ul><ul><li>-Moncton, NB </li></ul><ul><li>-Toronto North, ON </li></ul><ul><li>-Montréal Centre, QC </li></ul><ul><li>-Kitchener, ON </li></ul><ul><li>-Vancouver, BC </li></ul><ul><li>-Red Deer, AB </li></ul>15 Sites across Canada: -Quesnel / Williams Lake, BC -Edmonton, AB -Mauricie South, QC -Ville de Québec, QC -Northumberland County, ON -St-Catherine's, ON -Toronto East, ON Data collection completed February 25 2009
    24. 24. CHMS Clinic Operations & Support <ul><li>Clinic is open 7 days per week </li></ul><ul><li>Staffing: </li></ul><ul><ul><li>Manager </li></ul></ul><ul><ul><li>Logistics officer </li></ul></ul><ul><ul><li>Clinic Coordinators </li></ul></ul><ul><ul><li>Health Measures Specialists (HMS) </li></ul></ul><ul><ul><li>2 Dentists </li></ul></ul><ul><ul><li>Lab technicians </li></ul></ul><ul><ul><li>Admin staff </li></ul></ul><ul><ul><li>Interviewer manager </li></ul></ul><ul><ul><li>Interviewers </li></ul></ul>
    25. 25. CHMS Clinic Operations & Support <ul><ul><li>Central support for; </li></ul></ul><ul><ul><li>Advance arrangements </li></ul></ul><ul><ul><li>Public relations </li></ul></ul><ul><ul><li>Technical support </li></ul></ul><ul><ul><li>Training and retraining </li></ul></ul>
    26. 26.
    27. 27.
    28. 28. Mobile Examination Clinics
    29. 29.
    30. 30. <ul><li>Household Interview – 1.5 hours </li></ul><ul><li>Clinic - 2 hour appointment </li></ul><ul><li>Consent </li></ul><ul><li>Physical measures including oral health – 2hrs examination </li></ul><ul><li>Initial results immediately available </li></ul><ul><li>Final results in about 6 weeks </li></ul><ul><li>Confirm consent </li></ul>CHMS Household/Clinical Visit http://www.statcan.gc.ca/imdb-bmdi/instrument/5071_Q1_V1-eng.pdf http://www.statcan.gc.ca/imdb-bmdi/instrument/5071_Q2_V1-eng.pdf
    31. 31. Consent to Participate <ul><li>General consent </li></ul><ul><li>Proxy consent for children </li></ul><ul><li>Assent for children </li></ul><ul><li>Re-consent for children when they turn 14 </li></ul><ul><li>Data sharing </li></ul><ul><li>Data linking </li></ul><ul><li>Storage of biological samples </li></ul><ul><li>Reportable infectious diseases </li></ul>
    32. 32. Topics in the survey <ul><li>General Health </li></ul><ul><li>Chronic Conditions </li></ul><ul><li>Restriction of activities </li></ul><ul><li>Health utility index </li></ul><ul><li>Cognition </li></ul><ul><li>Physical activity </li></ul><ul><li>Sleep </li></ul><ul><li>Height and weight </li></ul><ul><li>Nutritional risk </li></ul><ul><li>Oral health </li></ul><ul><li>Medication use </li></ul><ul><li>Dietary supplement </li></ul><ul><li>Smoking </li></ul><ul><li>Alcohol use </li></ul><ul><li>Pain and discomfort </li></ul><ul><li>Falls </li></ul><ul><li>Health Care Utilization </li></ul>
    33. 33. Topics in the survey continued <ul><li>Home care & care receiving </li></ul><ul><li>Social participation </li></ul><ul><li>Care giving </li></ul><ul><li>Loneliness </li></ul><ul><li>Transportation </li></ul><ul><li>Labour force </li></ul><ul><li>Reason for retirement </li></ul><ul><li>Retirement planning </li></ul><ul><li>Income </li></ul><ul><li>Socio demographic characteristics </li></ul>
    34. 34. Self-report Questionnaire Content <ul><li>Health Status: </li></ul><ul><ul><li>General Health, Height and Weight, Weight Change, Health Utility Index, Chronic Conditions, Family Medical History, Oral Health </li></ul></ul><ul><li>Nutrition and Food Consumption </li></ul><ul><ul><li>Fruit and Vegetable, Meat and Fish, Dietary Fat, Salt and Other Food, Water and Soft Drink, Milk </li></ul></ul><ul><li>Medication Use </li></ul><ul><ul><li>Medications, Other Health Products and Herbal Remedies </li></ul></ul><ul><li>Health Behaviours </li></ul><ul><ul><li>Physical Activities, Sedentary Activities, Smoking, Alcohol Use, Illicit Drugs, Sexual Behaviour, Sleep </li></ul></ul><ul><li>Childhood Development </li></ul><ul><ul><li>Pregnancy, Birth and Breastfeeding Information </li></ul></ul><ul><li>Environmental Factors </li></ul><ul><ul><li>Exposure to Second-Hand Smoke, Housing Characteristics, Exposure to Toxic Chemicals, Sun exposure </li></ul></ul><ul><li>Socio-Economic Information </li></ul><ul><ul><li>Socio-Demographic Characteristics, Education, Labour Force Activity, Income </li></ul></ul>
    35. 35. Household – Self Reported <ul><li>Considerations: </li></ul><ul><ul><li>Establish time allowances </li></ul></ul><ul><ul><li>Negotiate and defend questions to keep included </li></ul></ul><ul><li>How to decide? The questions should </li></ul><ul><ul><li>meet the objectives of the oral health component of the CHMS </li></ul></ul><ul><ul><li>add context to the measures in clinical survey </li></ul></ul>
    36. 36. Household – Self Reported <ul><ul><li>The questions should - continued </li></ul></ul><ul><ul><li>allow comparison to questions in clinical component </li></ul></ul><ul><ul><li>allow comparison to international & national surveys </li></ul></ul><ul><li>Are there existing focus tested questions that meet your needs </li></ul><ul><ul><ul><li>i.e. NHANES & Canadian Community Health Survey (CCHS) </li></ul></ul></ul>
    37. 37. Focus testing of Household Questionnaire To determine: <ul><ul><li>If the questions flow smoothly </li></ul></ul><ul><ul><li>What to add to the interview guide to clarify potential queries on the questions </li></ul></ul><ul><ul><ul><ul><li>i.e. the use of Stimudent does not qualify as flossing </li></ul></ul></ul></ul><ul><ul><li>If the public’s interpretation of the questions are what was intended </li></ul></ul>
    38. 38. Focus testing continued <ul><ul><ul><li>In the past month, have you had: … persistent bad breath ? </li></ul></ul></ul><ul><ul><ul><li>The word persistent was added to isolate chronic and ongoing cases of bad breath, not simply as a result from eating garlicky food. </li></ul></ul></ul><ul><ul><li>Completed in both French and English </li></ul></ul>
    39. 39. <ul><li>Obesity </li></ul><ul><li>Heart disease </li></ul><ul><li>Lung disease </li></ul><ul><li>Diabetes </li></ul><ul><li>High blood pressure </li></ul><ul><li>Oral health </li></ul><ul><li>Growth and development in children </li></ul><ul><li>Ability to carry out the activities of daily life </li></ul>Health Issues
    40. 40. Physical Measures <ul><li>Anthropometry </li></ul><ul><ul><li>height, weight, waist circumference, sitting height </li></ul></ul><ul><ul><li>5 skinfolds </li></ul></ul><ul><li>Cardiorespiratory Fitness </li></ul><ul><ul><li>blood pressure </li></ul></ul><ul><ul><li>modified Canadian Aerobic Fitness Test (step test) </li></ul></ul><ul><ul><li>spirometry </li></ul></ul>
    41. 41. Physical Measures continued <ul><li>Musculoskeletal Fitness </li></ul><ul><ul><li>hand grip strength </li></ul></ul><ul><ul><li>sit-and-reach flexibility </li></ul></ul><ul><ul><li>curl-ups </li></ul></ul><ul><li>Physical Activity </li></ul><ul><ul><li>accelerometry </li></ul></ul><ul><li>Oral Health Exam </li></ul><ul><li>Biological Sample collection </li></ul><ul><li>(i.e; blood and urine) </li></ul>
    42. 42. Why Oral Health in the CHMS <ul><li>The objectives of including an oral health module in the CHMS include: </li></ul><ul><li>To evaluate the association of oral health with major health concerns such as diabetes, respiratory and cardiovascular diseases </li></ul><ul><li>To determine relationships between oral health and certain risk factors like poor nutrition and socioeconomic factors related to low income levels and education </li></ul><ul><li>To establish a national baseline level of the DMFT (Decayed, Missing and Filled Teeth) </li></ul>
    43. 43. Linkages between Oral Health and General Health <ul><li>Oral disorders affecting systemic conditions (e.g.: diabetes, aspiration pneumonia, adverse pregnancy outcomes, cardiovascular disease,) </li></ul><ul><li>Systemic disorders affecting oral tissues (e.g.: diabetes) </li></ul><ul><li>Medical syndromes (e.g.: osteogenesis imperfecta) </li></ul><ul><li>Oral conditions related to treatment for other systemic disorders (e.g.: loss of saliva due to radiation treatment) </li></ul><ul><li>Oral disease as a precursor of a systemic disease (e.g.: leukoplakia) </li></ul><ul><li>Oral disorders as markers of systemic diseases (e.g.: B12 deficiency; AIDS) </li></ul><ul><ul><li>-Oral Health in America: A report of the Surgeon General - http://www2.nidcr.nih.gov/sgr/sgrohweb/welcome.htm </li></ul></ul><ul><ul><li>-Locker D, Matear D. Oral disorders, systemic health, well-being, and the quality of life: a summary of recent research evidence. Toronto: Faculty of Dentistry, University of Toronto, 2001. </li></ul></ul>
    44. 44. Oral Health and Life Quality <ul><li>13% of adult Canadians have problems chewing </li></ul><ul><ul><li>33% over 65 cannot chew properly </li></ul></ul><ul><li>10% of adult Canadians have problems with speech </li></ul><ul><li>9% of adult Canadians report toothache once/month </li></ul><ul><ul><li>- Oral Health in America: A report of the Surgeon General - http://www2.nidcr.nih.gov/sgr/sgrohweb/welcome.htm </li></ul></ul><ul><ul><li>-A Canadian Oral Health Strategy - http://www.fptdd.ca </li></ul></ul><ul><ul><li>-Locker D, Matear D. Oral disorders, systemic health, well-being, and the quality of life: a summary of recent research evidence. Toronto: Faculty of Dentistry, University of Toronto, 2001. </li></ul></ul>
    45. 45. Oral Health and Life Quality <ul><li>Social interaction/employability/self-esteem </li></ul><ul><li>Productivity costs: </li></ul><ul><ul><li>Lost school days = 100,000 / year </li></ul></ul><ul><ul><li>Lost work days = 270,000 / year </li></ul></ul><ul><ul><li>Restricted activity days = 410,000 / year </li></ul></ul><ul><ul><li>- Oral Health in America: A report of the Surgeon General - http://www2.nidcr.nih.gov/sgr/sgrohweb/welcome.htm </li></ul></ul><ul><ul><li>-A Canadian Oral Health Strategy - http://www.fptdd.ca </li></ul></ul><ul><ul><li>-Locker D, Matear D. Oral disorders, systemic health, well-being, and the quality of life: a summary of recent research evidence. Toronto: Faculty of Dentistry, University of Toronto, 2001. </li></ul></ul>
    46. 46. Dental Professional and Family Physician Visits Statistics Canada, Health Division, Health Reports, Winter 1999 http://www.statcan.ca/english/ads/82-003-XPE/index.htm
    47. 47. Oral Health and Life Quality <ul><li>“… oral health and general health should not be interpreted as separate entities” </li></ul><ul><li>Surgeon General’s Report on Oral Health of America, 2000 </li></ul><ul><li>“ All people visit physicians. Young, healthy, wealthy, well educated people visit dentists”. </li></ul><ul><li>Sabbah W, Leake JL. Comparing characteristics of Canadians who visited dentists and physicians during 1993/94: A secondary analysis. JCDA, 2000, 66 (2): 90 </li></ul>
    48. 48. <ul><ul><li>A group of dental experts were brought together to advise on the development of the household and clinical survey. </li></ul></ul><ul><ul><li>Members include: </li></ul></ul><ul><ul><ul><li>Professional Associations </li></ul></ul></ul><ul><ul><ul><li>Regulatory Associations </li></ul></ul></ul><ul><ul><ul><li>Academics </li></ul></ul></ul><ul><ul><ul><li>Governments - Federal Provincial Territorial Dental Working Group Chair </li></ul></ul></ul><ul><ul><ul><li>Health Canada </li></ul></ul></ul><ul><ul><ul><li>Canadian Forces </li></ul></ul></ul>CHMS Oral Health Steering Committee
    49. 49. CHMS Oral Health Steering Committee <ul><li>Consideration </li></ul><ul><li>Bring together researchers, regulators, professional and government officials from the outset. This is an important step for guiding the development of the survey, the implementation through to the analysis. </li></ul>
    50. 50. Steering Committee Responsibilities <ul><li>1. Advise in gathering epidemiological information; </li></ul><ul><li>2. Develop the oral health module and the clinical survey; </li></ul><ul><li>3. Coordinate a pretest to assess the suitability and implementation of the clinical survey including the equipment, the qualitative questions and the calibration of examiners ; </li></ul>
    51. 51. Steering Committee Responsibilities <ul><li>4. Assist in the monitoring of the physical survey. </li></ul><ul><li>5. Provide advise for the 2010 Oral Health Report </li></ul>
    52. 52. <ul><ul><li>General health of the mouth </li></ul></ul><ul><ul><li>Satisfaction with appearance of teeth/dentures </li></ul></ul><ul><ul><li>Comfort/avoidance with eating food </li></ul></ul><ul><ul><li>Persistent or on-going pain anywhere in the mouth </li></ul></ul><ul><ul><li>Time away from work, school or normal activities because of dental check-ups, treatment or problems </li></ul></ul><ul><ul><li>Frequency of brushing/ flossing teeth/dentures </li></ul></ul><ul><ul><li>Frequency of seeing a dental professional </li></ul></ul><ul><ul><li>Insurance and cost issues </li></ul></ul>Household Survey Oral Health Questions
    53. 53. Self Report (Proxy) / Clinical Comparison of Dental Treatment needs in First Nations Children 1 First Nations Regional Health Survey Report; First Nations Centre, Laurier Ave. Ottawa, 2002/03. 2 Report on the 1996/97 Oral Health Survey of First Nations and Inuit Children in Canada - Aged 6 and 12. Health Canada 2000. Study Age of Children % in need of Restorative Care % in need of Urgent Care 1 Regional Health Survey 0 ->11 years 27 2 2 Oral Health Survey 6 & 12 years 63 8.4
    54. 54. <ul><li>Decide on the elements to be examined to allow comparisons to other countries e.g. Australia/Britain/USA </li></ul><ul><li>Choose indices to be used for examination </li></ul><ul><ul><li>Dean’s index vs. Tooth Surface Index of Fluorosis (TSIF) </li></ul></ul>Development of the clinical survey Some of the considerations
    55. 55. Considerations continued <ul><li>Age/health restrictions for certain questions </li></ul><ul><ul><li><18- no root assessments </li></ul></ul><ul><ul><li>Haemophiliac- no periodontal probing </li></ul></ul><ul><li>Expected Minimum/Maximum values for answers </li></ul><ul><li>Skip patterns (based on age, restrictions, dentate status, etc) </li></ul><ul><li>Order of questions to maximize skips </li></ul>
    56. 56. Oral Health Clinic Measures <ul><li>Dental status, i.e. dentate vs. edentulous </li></ul><ul><li>Prosthetic status </li></ul><ul><li>Mucosal status </li></ul><ul><li>Fluorosis status of children 6- 12 </li></ul><ul><li>Occlusal status </li></ul><ul><li>Orthodontic treatment status </li></ul>
    57. 57. Oral Health Clinic Measures <ul><li>Gingivitis, debris, calculus, attachment loss and probing </li></ul><ul><li>General tooth status (i.e. sound. decayed, extracted / missing, filled, etc) </li></ul><ul><li>Surfaces filled with amalgam </li></ul><ul><li>Trauma status </li></ul><ul><li>Untreated dental conditions </li></ul><ul><li>Prosthetic and treatment needs </li></ul>
    58. 58. <ul><li>Clinical survey developed in 4 separate blocks </li></ul><ul><ul><li>Oral Health Introduction </li></ul></ul><ul><ul><li>Oral Health Question </li></ul></ul><ul><ul><li>Oral Health Restriction </li></ul></ul><ul><ul><li>Oral Health Examination </li></ul></ul><ul><li>Each block, tested separately using fictional cases </li></ul><ul><ul><li>Do skips and edits function as expected? </li></ul></ul><ul><ul><li>Does the order of questions make sense? </li></ul></ul><ul><li>Another test of the clinical survey occurred once the blocks were integrated </li></ul>Oral Health Clinical Survey
    59. 59. Pre-test <ul><li>A pretest was held during the summer of 2006 </li></ul><ul><ul><li>10 respondents per age groups 6-11, 12-19, 20-31, 40-59, 60-79 </li></ul></ul><ul><li>Time estimates of the various age groups </li></ul><ul><ul><li>Including the greeting, exam, post exam verification, cleaning of room and preparation for next respondent </li></ul></ul>
    60. 60. Pre-test continued <ul><li>Test entire computer application to see if all skips were thought of or if some were too restrictive i.e. Amalgam question </li></ul><ul><li>Considerations </li></ul><ul><ul><li>Location </li></ul></ul><ul><ul><li>Coordinator/ Respondents </li></ul></ul><ul><ul><li>Timing and tracking of issues </li></ul></ul>
    61. 61. Oral Health Exam – questions/indices <ul><li>Block Testing </li></ul><ul><ul><li>Adjustments </li></ul></ul><ul><li>Pretest </li></ul><ul><ul><li>Adjustments </li></ul></ul><ul><li>Retesting </li></ul><ul><ul><li>Adjustments </li></ul></ul>Testing of Clinical Survey <ul><li>Calibration session </li></ul><ul><ul><li>Adjustments </li></ul></ul><ul><li>Dental Recorder Training </li></ul><ul><li>Dress rehearsal </li></ul><ul><ul><li>Adjustments </li></ul></ul>
    62. 62. Staffing for the Oral Health Component of the CHMS <ul><li>Examiners </li></ul><ul><ul><li>Canadian Forces dentists </li></ul></ul><ul><ul><li>Partnership with Health Canada </li></ul></ul><ul><li>Dental Recorders </li></ul><ul><ul><li>Non health background for dental recorders </li></ul></ul><ul><ul><li>Trained to enter data, manage dental room & operate sterilizer </li></ul></ul>
    63. 63. Staffing continued <ul><li>WHO Gold Standard Dentists </li></ul><ul><ul><li>1 st calibration session trained 2 Canadian Dentists to run sessions Consideration </li></ul></ul><ul><ul><li>Who is available for the data collection </li></ul></ul><ul><ul><li>Background </li></ul></ul><ul><ul><li>Licensing issues </li></ul></ul><ul><ul><li>Training requirements </li></ul></ul>
    64. 64. Examples of Equipment For the Oral Health Room <ul><li>Dental chair light/ Instrument arm tray </li></ul><ul><li>Stool for dentist/dental recorder/ parent </li></ul><ul><li>1 keyboard and 2 monitors </li></ul><ul><li>Autoclave </li></ul><ul><li>Sink </li></ul><ul><li>Examination packages </li></ul><ul><ul><li>Williams probe </li></ul></ul><ul><ul><li>Mouth mirror </li></ul></ul><ul><ul><li>Gauze/cotton rolls </li></ul></ul>
    65. 65. Equipment continued <ul><li>Bins for instruments </li></ul><ul><li>Cupboard space/ racks for bin storage/ tub & tray </li></ul><ul><li>Garbage can </li></ul><ul><li>Goggles </li></ul><ul><li>Hand held mirror </li></ul><ul><li>Mouth model </li></ul><ul><li>Consideration: </li></ul><ul><li>Size and placement of all materials </li></ul>
    66. 66. Equipment continued <ul><ul><li>Infection control materials </li></ul></ul><ul><ul><ul><li>Surface cleaner </li></ul></ul></ul><ul><ul><ul><li>Instrument soak </li></ul></ul></ul><ul><ul><ul><li>Plastic sleeves for chair/tray </li></ul></ul></ul><ul><ul><ul><li>Masks/ Gloves </li></ul></ul></ul><ul><ul><ul><li>Sterilizer bags </li></ul></ul></ul><ul><ul><ul><li>Spore tests </li></ul></ul></ul><ul><ul><ul><li>Instrument cleaner/brush </li></ul></ul></ul>Consideration: Disposable versus reusable instruments Sterilizing process Number of instruments required to have enough for a week Frequency of spore testing- impact the # of instruments
    67. 67. Dress rehearsal <ul><li>A dress rehearsal was held during February & March 2007 </li></ul><ul><ul><li>ensured the timing and flow of respondents and information </li></ul></ul><ul><ul><li>provided the dentists & dental recorders an opportunity to work together </li></ul></ul><ul><ul><li>tested the physical setup of the mobile examination clinic </li></ul></ul>
    68. 68.
    69. 69.
    70. 70. First Nations and Inuit Oral Health Surveys <ul><li>Both surveys will: </li></ul><ul><li>Collect national level data </li></ul><ul><li>Use CHMS as basis therefore will be comparable with the CHMS </li></ul><ul><li>Collect data between April 1/08- fall, 2009 </li></ul><ul><li>Include children Age 3-5 </li></ul><ul><li>Jointly analyze data and </li></ul><ul><li>Utilize Health Canada dentists as examiners </li></ul><ul><li>Utilize Health Canada dental examiners </li></ul>
    71. 71. <ul><li>Language </li></ul><ul><li>Interviewer safety </li></ul><ul><li>Staff concerns about sterilizer </li></ul><ul><li>Calibration </li></ul><ul><ul><li>Where to hold </li></ul></ul><ul><ul><li>volunteers to examine </li></ul></ul><ul><ul><li>Scheduling and organizing </li></ul></ul><ul><li>Sterilization – on-site or central </li></ul><ul><li>Transportation and lodging </li></ul><ul><li>Equipment problems </li></ul>Examples of Potential Challenges
    72. 72. Challenges continued <ul><li>Obtaining accurate lists of respondents </li></ul><ul><li>Shipping – items may freeze </li></ul><ul><li>Power outages, weather holds </li></ul><ul><li>Obtaining examiners </li></ul><ul><li>Attracting respondents participation </li></ul>
    73. 73.
    74. 74. Challenges continued <ul><li>Staff training </li></ul><ul><ul><li>Interviewers </li></ul></ul><ul><ul><li>Coordinators </li></ul></ul><ul><ul><li>Cross training </li></ul></ul><ul><ul><li>Video Conference </li></ul></ul><ul><li>Facilitating access to treatment services through the appropriate local groups. </li></ul>
    75. 75. Examiners <ul><li>CHMS used dentists </li></ul><ul><li>Hygienists and dental therapists have been calibrated. </li></ul><ul><li>Regulatory issues </li></ul><ul><ul><li>Each jurisdiction different </li></ul></ul><ul><ul><li>CHMS used dentists as the only provider accepted in all jurisdictions to do the examinations. </li></ul></ul><ul><li>Choice of examiner would depend on the type of survey and jurisdictional issues. </li></ul>
    76. 76. Data Value and Analysis Potential <ul><li>Endless Possibilities </li></ul><ul><li>Income / attendance / oral health status </li></ul><ul><li>Tobacco use / alcohol use and periodontal health </li></ul><ul><li>Blood mercury levels and amalgams </li></ul>
    77. 77. Possibilities continued <ul><li>Preventive practices / deft:DMFT / Periodontal status </li></ul><ul><li>Unknown correlations with blood / urine chemistry </li></ul><ul><li>Human Resource Planning </li></ul><ul><li>Further research needs </li></ul>
    78. 78. Data Storage and Access <ul><li>CHMS </li></ul><ul><ul><ul><li>data owed by Statistics Canada </li></ul></ul></ul><ul><ul><ul><li>Stored by Statistics Canada </li></ul></ul></ul><ul><ul><ul><li>Access* available by: </li></ul></ul></ul><ul><ul><ul><ul><li>On-site at Statistics Canada Ottawa </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Research Data Centres (RDCs) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Data request to Statistics Canada </li></ul></ul></ul></ul>*Data access fees may apply
    79. 79. Data Storage and Access <ul><li>Inuit Survey </li></ul><ul><ul><li>led by Health Canada (OCDO) with our Inuit partners. </li></ul></ul><ul><ul><li>Data to be stored by Health Canada via MOU with the Inuit Tapiriit Kanatami (ITK) </li></ul></ul><ul><ul><li>Access to data – requests come to Health Canada reviewed and approved by ITK. Only data that would not identify individuals would be released. </li></ul></ul><ul><ul><li>Training for interviewers done via videoconference </li></ul></ul>
    80. 80. Data Storage and Access <ul><li>First Nations Survey </li></ul><ul><ul><li>Led by Assembly of First Nations with Health Canada as partner </li></ul></ul><ul><ul><li>Data stored by AFN </li></ul></ul><ul><ul><li>Access* requests through AFN </li></ul></ul>*Data access fees may apply
    81. 81. Oral Health Report Card 2010 <ul><li>Technical report </li></ul><ul><li>Public report </li></ul>
    82. 82. Oral Health Report Card 2010 <ul><li>Technical report </li></ul><ul><ul><li>Aimed at private/public oral health professionals and academics </li></ul></ul><ul><ul><li>Contractor in place to develop and format normative data tables; disease prevalence, Scio-demographic characteristics </li></ul></ul><ul><ul><li>Oral Health Survey Methods and tools </li></ul></ul><ul><ul><li>Oral health in Canada past and present </li></ul></ul><ul><ul><li>Research current status and direction </li></ul></ul>
    83. 83. Oral Health Report Card 2010 <ul><li>Public Report </li></ul><ul><ul><li>Developed from the technical report </li></ul></ul><ul><ul><li>Aimed at the general public and other health professionals </li></ul></ul><ul><ul><li>Executive Summary for political and policy audience </li></ul></ul>Spring 2010 target date for commencement of release.
    84. 84. Oral Health Report Card 2010 <ul><li>CHMS – National level data </li></ul><ul><ul><li>Canadian Population </li></ul></ul><ul><ul><ul><li>Back ground and history of oral health surveys in Canada </li></ul></ul></ul><ul><ul><ul><li>Disease Prevalence (DMFT, deft), Fluorosis status, self reported measures </li></ul></ul></ul>
    85. 85. Oral Health Report Card 2010 <ul><li>CHMS – National level data continued </li></ul><ul><ul><ul><li>Socio-demographic – e.g. income, education </li></ul></ul></ul><ul><ul><ul><li>Vignettes – highlighting items that are working well </li></ul></ul></ul><ul><ul><ul><li>Comparisons to other countries </li></ul></ul></ul><ul><ul><ul><li>Review of Oral Health research in Canada </li></ul></ul></ul>
    86. 86. Report Process Steps <ul><li>Technical Contract - normative tables, history, background </li></ul><ul><li>Steering Committee - to review and provide feedback </li></ul><ul><li>Federal Dental Care Advisory Committee to review and provide feedback </li></ul><ul><li>Finalize the technical report </li></ul><ul><li>Public Report- Executive Summary – Review and finalize </li></ul><ul><li>Report release target Spring 2010 </li></ul>
    87. 87. Sub Group Publications <ul><li>Inuit Oral Health Survey – led by the OCDO </li></ul><ul><li>First nations Oral Health Survey - led by AFN </li></ul><ul><li>The Oral Health of our Aging Population- Dalhousie university </li></ul><ul><li>Homeless Oral Health Survey – led by University of Toronto </li></ul>The release of these reports targeted for fall winter 2010
    88. 88. Calibration and Training - CHMS <ul><li>World Health Organization (WHO) Gold Standard </li></ul><ul><li>2 Gold Standard Dentists </li></ul><ul><li>Calibration session 5 days </li></ul><ul><li>Recalibration at start of each site </li></ul><ul><li>2 day training for dental recorders </li></ul>
    89. 89. Desirable characteristics of an index <ul><li>Valid </li></ul><ul><li>Reliable </li></ul><ul><li>Acceptable </li></ul><ul><li>Easy to use </li></ul><ul><li>Amenable to statistical analysis </li></ul>
    90. 90. Validity and Reliability Valid Yes Reliable Yes Valid No Reliable Yes Valid no Reliable No Unbiased Valid No Reliable No Biased
    91. 91. Validity <ul><li>Success in measuring what you set out to measure </li></ul><ul><li>Gold Standard ensures validity </li></ul><ul><ul><ul><li>i.e. that we are measuring what we propose to measure </li></ul></ul></ul><ul><ul><ul><li>That we are all measuring the same thing…”singing out of the same hymn book” </li></ul></ul></ul>
    92. 92. Reliability <ul><li>The extent to which the clinical examination yields the same result on repeated inspection. </li></ul><ul><li>Inter-examiner reliability: reproducibility between examiners. </li></ul><ul><li>Intra-examiner reliability: reproducibility within examiners. </li></ul>
    93. 93. Reliability <ul><li>Calibration ensures inter and intra examiner reliability and allows: </li></ul><ul><ul><li>International comparisons </li></ul></ul><ul><ul><li>Regional comparisons </li></ul></ul><ul><ul><li>Temporal comparisons </li></ul></ul><ul><li>Without calibration </li></ul><ul><ul><li>Are any differences real or due to examiner variability? </li></ul></ul>
    94. 94. Examiner Reliability Statistics <ul><li>Percent Agreement and Kappa Statistic </li></ul><ul><li>Used when: </li></ul><ul><li>Training and calibrating examiners in a new index against a Gold Standard Examiner </li></ul><ul><li>Re-calibrating examiners against a Gold Standard Examiner </li></ul>
    95. 95. CHMS FN & Inuit Training and Calibration <ul><li>Training for continued: </li></ul><ul><li>Orthodontic Treatment Status </li></ul><ul><li>Periodontal Assessments </li></ul><ul><li>Tooth Status </li></ul><ul><li>Amalgam Count </li></ul><ul><li>Traumatic Injury </li></ul><ul><li>Treatment Needs </li></ul><ul><li>Training for: </li></ul><ul><li>Dentate Status </li></ul><ul><li>Prosthetic Status </li></ul><ul><li>Mucosal Status </li></ul><ul><li>Fluorosis </li></ul><ul><li>Orthodontic Status </li></ul>
    96. 96. CHMS FN & Inuit Training and Calibration <ul><li>Calibration for: </li></ul><ul><li>Fluorosis </li></ul><ul><li>Orthodontic Status </li></ul><ul><li>Periodontal Assessments </li></ul><ul><li>Tooth Status </li></ul><ul><li>Amalgam Count </li></ul>Magnification is not allowed for examinations
    97. 97. Calibration session Considerations: <ul><li>Location </li></ul><ul><ul><li>Need dental chairs available (dental training facility or portable equipment) </li></ul></ul><ul><li>Trainers </li></ul><ul><ul><li>WHO Gold standard level </li></ul></ul><ul><ul><li>Run the session and to whom the dentists calibrate against </li></ul></ul><ul><li>Coordinator </li></ul><ul><ul><li>Logistics/obtaining consent & health restrictions/entering data </li></ul></ul>
    98. 98. Calibration session Considerations: <ul><li>Respondents </li></ul><ul><ul><li>Variety of ages and dental conditions </li></ul></ul><ul><li>Fluorosis & Periodontal Indices </li></ul><ul><ul><li>Difficult to calibrate; allow enough time </li></ul></ul><ul><li>Analyzing results </li></ul><ul><ul><li>percent agreement & Cohen’s kappa scores calculated where possible </li></ul></ul><ul><li>Updating Protocol Manual </li></ul><ul><ul><li>A few issues arose to be addressed by the Steering Committee </li></ul></ul>
    99. 99. Ongoing training and quality control <ul><li>CHMS </li></ul><ul><li>Dry run day </li></ul><ul><ul><li>One day at the start of each site </li></ul></ul><ul><li>Fluorosis testing </li></ul><ul><ul><li>Done at least 2 times per site (usually 3) </li></ul></ul><ul><li>Recalibration on elements </li></ul><ul><ul><li>As required </li></ul></ul>
    100. 100.
    101. 101. Questions/Discussion

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