Question

Using the Proceed-Precede Model, Apply a population based health program involving the planning, implementation, and evaluation phases for evaluating the poor personal hygiene strategy for adults among mentally challenged/disabled population

Answer 1

Although the poor oral health of adults with intellectual and developmental disabilities (IDD) constitutes a significant health disparity in the United States, few interventions to date have produced lasting results. Moreover, there is minimal application of planning models to inform and design a theory-based strategy that has the potential to be effective and sustainable in this population.

The PRECEDE-PROCEED planning model is being used to design and evaluate an oral health strategy for adults with IDD. The PRECEDE component involves assessing social, epidemiological, behavioral, environmental, educational, and ecological factors that informed the development of an intervention with underlying social cognitive theory assumptions. The PROCEED component consists of pilot-testing and evaluating the implementation of the strategy, its impact on mediators and outcomes of the population under study.

PRECEDE Planning Model Component

We used an extensive literature review and informal discussions with selected community leaders and staff who work with IDD population in a targeted Midwestern city. These participants consisted of one vice president, one residential director, and three caregivers working in group homes of one IDD service organization, and two dentists and three dental hygienists/assistants who work with IDD population. In total, interview data were collected from 10 IDD and dental care persons. Each of these participants engaged in an informal discussion that posed questions central to the assessment of phases 1-4. A content analysis of the literature and discussions produced the results presented later.

Phase 1 - Social Assessment

The PRECEDE portion of the Model begins with diagnostic activities that identify desirable outcomes or goals of the intervention or ask, “What can be achieved?” These activities determined the primary or distal outcomes of the oral health strategy for the individual with disabilities.

Phase 2 - Epidemiological, Behavioral, and Environmental Assessment

We searched the literature and asked questions of the selected community leaders and healthcare staff noted above about what problems or issues affect the oral health-related quality of life for persons with IDD? - OR - What needs to change to achieve optimal oral health for these individuals? This phase determined epidemiological, behavioral, and environmental factors that may well have an impact on the oral health and quality of life of individuals with IDD. This phase contributed to the identification of the factors that an oral health strategy needs to impact (mediating outcomes) in order to achieve the primary outcomes.

Phase 3 - Educational and Ecological Assessment

This phase determined factors that, if modified, would be most likely to result in behavior change and to sustain this change process. These factors are generally classified as predisposing, enabling, and reinforcing factors .“Predisposing factors are antecedents to behavior that provide the rationale or motivation for the behavior” and include individuals’ existing skills and self-efficacy. “Enabling factors are antecedents to behavioral or environmental change that allow a motivation or environmental policy to be realized” and may include new skills, services, resources, and programs. Reinforcing factors are those factors following a behavior that provide continuing reward or incentive for the persistence or repetition of the behavior” and they include social support, praise, and vicarious reinforcement.

Change theory(ies) for designing the intervention after this assessment includes individual, interpersonal, and community theories. Individual-level theories are best used to address predisposing factors, while interpersonal-level theories, such as social cognitive theory, address reinforcing factors well; community-level theories are most appropriate for addressing enabling factors.

Phase 4 - Intervention Alignment and Administrative and Policy Assessment

Phase 4a - Intervention Alignment

This phase matched appropriate strategies and interventions with the projected changes and outcomes identified in phases 1-3 .Using assessment results from phases 1-3, the oral health strategy presented in the results section emerged as our intervention of choice.

Phase 4b - Administrative and Policy Assessment

In this phase, resources, organizational barriers and facilitators, and policies that were needed for the strategy or intervention implementation and sustainability were identified .The organizational and environmental systems that could affect the desired outcomes (enabling factors) were taken into account. The administrative diagnosis assessed resources, policies, budgetary needs, and organizational situations that could hinder or facilitate the development and implementation of the strategy or program . The policy diagnosis assessed the compatibility of the oral health strategy with those of the organizations providing services to individuals with IDD.

PROCEED Planning Model Component

Phase 5 - Pilot Study

Although we did not recognize the inclusion of a pilot study as essential to the PRECEDE-PROCEED planning model, we believe that it is an important planning phase. These results and lessons learned are important to revising both the pilot oral health strategy and its evaluation for an efficacy study. To this end, we have provided a description of our inprogress pilot study in the results section of this article.

Phase 6 - Implementation

This phase presents a description of the implementation of the oral health strategy in an efficacy study. Key roles in the implementation phase are highlighted.

Phases 7 and 8 - Process and Outcome Evaluation

Our planned efficacy study is designed as a cluster randomized control trial that includes a process and outcome evaluation. The study of both the implementation process and outcome achievements is important. The implementation process assessment should address the amount of intervention exposure of the oral health strategy (dosage), extent to which an intervention is implemented as designed (fidelity), and participant appraisal of intervention quality or usefulness (participant reaction), all of which are discussed in the evaluation literature .In addition, we measured adequacy of implementation by recruiting an expert panel who has published implementation articles to assess the adequacy of our implementation . The outcome evaluation should be composed of an assessment of oral health strategy direct effects on outcomes, mediation of outcomes designated as mechanisms of change, and moderation of contextual factors.

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PRECEDE Phase 1 - Social Assessment

Our social diagnosis began while we were conducting previous studies in long-term care facilities and in community settings for persons with IDD. During this planning phase, we solicited input from the community (direct care staff, administrators, and dental professionals who care for persons with IDD), and they all stated that poor oral health is one of the greatest unmet health care needs of their population .The community was also becoming aware of the association of aspiration of bacteria from the mouth into the lungs with respiratory infections, and it wanted to improve oral health and oral health-related quality of life including respiratory health.

PRECEDE Phase 2 - Epidemiological, Behavioral, and Environmental Assessment

A. Epidemiological Assessment

Historically, children and adults with mild to profound intellectual and developmental disabilities (IDD) either lived at home or were placed in large state institutions with fully staffed medical and dental facilities and stable, well-trained workers. Over the past several decades, a major effort to deinstitutionalize these individuals and place them in smaller community residences has been successful. Although overall quality of life may have been improved for this vulnerable population, their access to dental care has become limited or non-existent, and their oral health has suffered . A majority of persons with IDD are insured by Medicaid, and many dentists either do not accept Medicaid or do not believe they are adequately trained to treat special-needs patients.

The oral health of this population is compromised not only by the lack of preventive dental treatment every six months but also by their inability to adequately brush and/or floss their own teeth. The oral hygiene provided or supervised by caregivers is thus critical to maintaining oral health and reducing the need for extensive restoration or extraction of teeth. Providing oral care for individuals with IDD is challenging, not only because they may have physical impairments but also because they exhibit uncooperative behaviors . Caregivers often only clean the anterior teeth, ignoring the posterior teeth and causing the posterior oropharyngeal area to be at risk for colonization with bacteria and infection .

Swallowing disorders (dysphagia) are common in persons with developmental disabilities, putting them at risk for aspiration and respiratory infections, a major cause of morbidity and mortality in this population .Similar to what occurs with elderly persons residing in nursing homes and patients in intensive care units, potentially pathogenic bacteria colonize the oropharyngeal area of people with IDD. Rigorous oral hygiene can reduce oral colonization with bacteria and yeasts, thus reducing pneumonia in at-risk individuals .

Although social initiatives that focus on increasing the number of dentists who will treat special-needs patients are needed, it remains the purview of the caregiver to supervise and/or provide oral hygiene. Thus, theoretically sound strategies or interventions that address the caregiver's behavioral capability in providing oral health support may reduce disparities and could be imperative for improving health and quality of life in this population.

B. Behavioral Assessment

We determined key behavioral factors of the individual with IDD that affect mechanisms impacting their oral health and quality of life. Individuals with IDD have physical, behavioral, and cognitive disabilities that negatively impact their ability to perform their own oral hygiene practices at an optimal level .Those with mild disability, who are capable of performing their oral hygiene, frequently do not prioritize brushing or flossing their teeth on a regular basis and often do not know how to perform these practices optimally. Those with moderate to profound disabilities may be able to partially perform their oral hygiene, but they often require assistance and/or supervision provided by caregivers to adequately clean their teeth. Also, due to their emotional and unpredictable episodes, as the caregivers call them, all IDD persons may exhibit uncooperative and/or resistant behaviors from time to time that prevent them from engaging in oral hygiene practices regularly.

Like the parents of very young children, caregivers also play a key role in shaping the behavior of adults with IDD, who frequently have a mental age lower than that of a 5-year-old child without disability. Adults with disabilities generally do not achieve an acceptable standard of oral health on their own. However, Shaw and colleagues demonstrated that if these IDD persons are supervised, encouraged, and motivated by caregivers, their oral hygiene can be improved .Caregiver behavior in the form of support of the adult with IDD oral health, coupled with the caregiver's self-efficacy in promoting the adult's self-care behavior, should improve the residents’ oral hygiene practices.

C. Environmental Assessment

We identified environmental barriers or influences that are key factors in social cognitive theory. First, the physical environment in group homes is frequently not conducive to optimal oral hygiene practices. Materials available for oral hygiene usually include only over-the-counter toothbrushes, which may not be adequate to address the residents’ disabilities.

Second, our assessment of the social environment in the group homes determined that there were no policies or procedures in place concerning oral health or oral hygiene practices. Implementation of policies and procedures related to oral health by the organizations that manage the group homes would provide all caregivers with guidelines for and expectations of their performance. We found that all caregivers are responsible for preparing either breakfast or dinner during the week, and on weekends they must prepare all meals and/or take the residents out to lunch. As such, they are the primary persons responsible for determining what the residents eat and drink while in their care and they hold the responsibility of ensuring the availability of an appropriate diet in the group home setting to reduce the risk of tooth decay.

PRECEDE Phase 3 - Educational and Ecological Assessment

A. Predisposing Factors

We identified potential factors that may need to be modified to effect changes in caregiver behavior. We identified these factors based on discussions with our community leaders and a review of the literature. These social cognitive factors-self-efficacy, outcome expectancies, and behavioral capability-may be important because merely providing education to caregivers in oral hygiene provision for dependent persons has been shown to be minimally effective in improving oral health .

Self-efficacy is defined as “people's judgments of the capabilities to organize and execute courses of action required to attain designated types of performances” .Self-efficacy in oral hygiene, or the perceived ability or confidence of an individual to perform good tooth brushing and flossing, has been shown to be important in previous oral health studies .Caregivers reported to us that they had knowledge of the importance of oral health but stated that they were not comfortable supervising or assisting the residents in oral hygiene procedures. The literature reports that parental/caregiver self-efficacy in supporting or supervising young children's oral hygiene can be a strong predictor of parental/caregiver oral hygiene support .

Outcome expectancies are defined as “a person's estimate that a given behavior will lead to certain outcomes” or beliefs about the likelihood and value of behavioral choices. Caregiver psychosocial factors, such as expectations of poor oral health in their residents/clients, may serve as a barrier to optimal oral hygiene behavior . Outcome expectancies may be impacted by individuals seeing like individuals perform the behavior and/or encouragement to them that they are capable of performing the behavior .Demonstrations of oral health behaviors by a dental hygienist and the subsequent modeling of the behavior by the caregivers may impact their outcome expectancies of providing oral health support.

Behavioral capability is defined as someone's actual ability to perform a behavior in real-life situations. A caregiver must know what oral health support behavior is and have the skills to perform it. Informal interviews conducted with caregivers (direct care staff) in the group homes revealed that they received virtually no training or support in supervising or providing oral health services or dietary supervision for their adults with IDD. As previously stated, we know that providing only didactic training to caregivers does not result in improved resident oral health ,which suggests that building behavioral capability is also necessary.

B. Enabling Factors

Our literature review identified factors external to the caregivers and adults with IDD that could be impacted by our strategy to improve oral health. These factors-planned action, capacity building, and environmental adaptation-would be antecedents to the behavior change we hoped to impact. We believe these enabling factors should be intervention components of our oral health strategy.

Planned action is an enabling factor that has been shown to impact caregiver behavior and is a key construct of the Health Action Process Approach .Interventions reported in the obesity and cardiovascular literature that begin with a plan and a behavioral contract between the parents/ caregivers and researchers to complete the plan have been effective . In addition, young children whose parents had set goals using an action plan demonstrated significantly reduced plaque scores and improved gingival health compared to a control group who had no planned actions . Similarly, children with plans for asthma and obesity actions showed marked improvement in their health . Glassman and colleagues recommend that adults with IDD should have an oral health care action plan .

Capacity building is the process through which the abilities to do certain things are obtained, strengthened, adapted, and maintained over time . Capacity building was used by community health workers to promote oral health among women and mothers, and this resulted in significant changes in oral health expectancies, self-efficacy, and oral health behaviors . We believe that the strategy must include a comprehensive capacity-building component that will provide not only didactic training but also observational learning and skill development throughout the duration of the strategy. In addition, providing the caregiver with training and skills in dietary supervision may enable him/her to improve the oral health of the residents.

Environmental adaptation utilizing oral hygiene aids, such as special toothbrush handles for individuals who have poor coordination or diminished ability to grip, mouth props, multi-surface brushes (Surround or Collis), powered brushes, dental floss alternatives, and flavored toothpaste, may also improve caregiver behavioral capability and the oral health of adults with IDD . Caregivers may also need to alter the physical environment where they provide oral hygiene for residents who are partially or fully dependent by performing these procedures in an area of the home other than the restroom . Reclining the resident on a bean bag or sofa can facilitate resident's cooperation and reduce potential for injury to the resident or care-giver. Finally, the social environment in the home could be adapted by the implementation of policies and procedures regarding oral health to influence the caregivers’ behavior.

C. Reinforcing Factors

Reinforcing a desired behavior is an important construct in social cognitive theory, and it encourages a behavior to be repeated and sustained. We identified two intervention components-coaching and monitoring oral health practices-that could impact caregiver self-efficacy, outcome expectancies, behavioral capabilities, and environmental influences.

The literature suggests that ongoing coaching of the caregiver and resident is essential to the success of an oral health strategy for persons with IDD (5). There is some evidence that continued follow-up with caregivers and feedback on plaque removal are needed to improve oral hygiene practices, as well as to effect significant and sustainable change in oral health .

In addition to coaching, a web-based monitoring system can enable the ability to provide constructive reinforcement to caregivers on a regular basis. Residents also need reinforcement from the caregiver when they perform their oral hygiene or when they cooperate with caregiver-provided oral hygiene . The proposed oral health strategy will also include coaching and monitoring of the caregivers, and building the caregiver's capacity to reinforce and monitor the residents’ oral health and oral hygiene practices.

PRECEDE Phase 4a - Intervention Alignment

Based on the analysis of the assessments in phase 1-3, we constructed an intervention strategy. The PRECEDE activities identified predictors of the caregivers’ and individual residents’ targeted health behaviors. We then conducted a search of the literature for health behavior theories that would allow for testing of mechanisms of change and thereby inform our intervention techniques. We determined that two theories, SCT and HAPA, incorporate concepts that are aligned with the results of our assessments during PRECEDE activities.

We used four constructs from the two theories to assess their impact as mechanisms of change or mediating variables in the strategy framework: self-efficacy, behavioral capability, and environmental influences from SCT, and outcome expectancies constructs from both SCT and HAPA. We posit links between the determinants of the targeted oral health of an IDD population and our theory-based oral health strategy described below. We took into account factors identified during the PRECEDE activities including enabling factors (planned actions from HAPA, capacity building, environmental adaptation, and reinforcement from SCT). These enabling factors formed our four-component oral health strategy-planned action, capacity building, environmental adaptations, and reinforcement activities.

Planned action will involve a behavioral contract with the caregivers, who will be asked to make a contract with the research team to participate in the oral health strategy and the development, implementation, and monitoring of oral health plans for each consented individual with IDD in their care. Capacity building will be facilitated by a dental hygienist who will provide training to increase the behavioral capability of the caregiver in providing oral health support to the individuals with IDD. Environmental adaptations will occur when the hygienist works with caregivers to select and use various oral hygiene aids and dental devices to improve oral hygiene practices. The implementation of oral health policies and procedures will adapt the group home environment to impact caregiver outcome expectations. Reinforcement will occur during follow-up coaching visits by the hygienist with the caregivers and individuals with IDD, and the web-based monitoring will also provide reinforcement to the caregivers.

PRECEDE Phase 4b - Administrative and Policy Assessment

We determined in our administrative assessment that an oral health strategy would need the following key factors: (1) support of the organizations that provide community services for the individual residents with IDD and (2) behavioral contracts with the Directors of Residential Services of these organizations to delineate the roles and responsibilities of these key individuals.

Our policy assessment determined that if the oral health strategy were to be successful, the following would be needed: (1) a randomized controlled trial to produce evidence of impact on oral health outcomes, (2) implementation of a monitoring policy by the organization providing services for the adults with IDD, and (3) preliminary evidence of the sustainability of the strategy.

PROCEED Model Component

The PROCEED component entails conducting a pilot study to refine the oral health strategy (phase 5a), implementing the strategy (phase 5b), and testing the efficacy of the strategy under experimental conditions (phases 6-8). The larger study would be designed to assess intervention processes (phase 6), impact on mediators (phase 7), and outcomes relating to the oral health and quality of life of adults with IDD (phase 8).

PROCEED 5 - Pilot Study

The pilot study is part of an in-process R34 grant from the NIDCR. This study is examining the oral health strategy described in this article using a pre-post intervention design only. The participants are consented caregivers and adults with IDD in 12 group homes managed by a large organizational network serving the IDD population in one Midwestern city. The pilot study assesses (a) dosage [amount of intervention exposure of each strategy component], (b) implementation fidelity [extent to which each component is implemented as designed], and (c) participant reactions [appraisal of the quality or usefulness of the strategy] that are associated with implementing the strategy over a condensed one-month time period. In addition, we are assessing change in the study outcomes as preliminary results to guide development of the final oral health strategy. Also, the reliability and validity of our process and outcome measures and the feasibility of various data-collection procedures (such as using video cameras to collect observation data in a group home setting) are being examined in this in-process NIDCR grant. The analytical strategies for the pilot test will involve the use of simple descriptive statistics in the form of frequencies and percentages for the process assessment (phase 5a) and linear or logistic regression for assessing changes in the proximal, intermediate, and distal outcomes.

PROCEED 6 - Implementation of the Oral Health Strategy

Assuming the pilot study results demonstrate the feasibility of a larger RCT study, we plan to apply for a second NIDCR grant in the near future. In sequence, the oral health strategy will be implemented after obtaining written informed consent and HIPAA authorization from the caregivers and the parents or guardians of the adults with IDD. First, a behavioral contract will be negotiated with the caregivers to participate in a program to improve the oral health of their residents.

Second, the strategy is designed to promote capacity building in the caregiver by requiring skills training in providing and/or supervising oral hygiene practices for the IDD resident, dietary supervision, and planning and monitoring goals for oral health care. All components and Key Points of the following three capacity-building parts of the intervention are included in a Manual of Procedures for the study, which is required in the NIDCR-funded pilot study. Initially, didactic training will be provided in the group homes to groups of caregivers. The training has been adapted from the Overcoming Obstacles program ,which includes a PowerPoint presentation and a 20-minute DVD demonstrating oral hygiene and behavioral management techniques. Caregiver capacity building will continue during in-home training immediately after the didactic training and will be provided by the dental hygienist with at least two caregivers and the three adults with IDD residing in the home. The in-home training begins with a discussion of each resident's current oral hygiene practices and any existing behavioral challenges to oral health. The hygienist and caregivers will then cooperatively develop individualized oral healthcare plan goals for each resident. During this initial in-home visit the dental hygienist will provide opportunities for observational learning by performing oral hygiene procedures for each IDD resident while the caregivers watch. The caregivers will then be encouraged to model the same hygiene practices while the hygienist watches and offers suggestions for improvement, praise, reassurance, and encouragement.

Third, because each resident will have unique needs for environmental adaptation, the dental hygienist will work with each caregiver throughout the intervention to find and evaluate adaptive devices and/or behavioral strategies that will produce the greatest benefit for the resident by increasing participation and cooperation. The environment in the group homes will also be adapted by providing caregivers on-line technology to document on a daily basis the resident's self-care behavior, including oral hygiene practices and diet. The on-line technology will also facilitate reinforcement of the caregivers’ study activities.

Fourth, the dental hygienist will also assist the caregivers in selecting and assessing reinforcements that will improve IDD participant cooperation. During this time, there will also be training for the caregivers on how to record video observations and daily logs that capture the IDD residents’ oral hygiene practices. During the subsequent four in-home capacity-building visits (coaching visits), the dental hygienist will coach the caregivers in ways to improve supervising and/or providing oral hygiene practices, supervising residents’ diets, and planning and monitoring the residents’ oral health. At the end of the intervention, the caregivers and dental hygienist will review the behavioral contract, evaluating how well each caregiver met the expectations of participation in the intervention.

Process and Outcome Evaluation

For the efficacy study, we propose an oral health strategy to be implemented over a four-month period. The implementation process measures include dosage, fidelity, and participant reaction as described above. To test for effects on the proximal outcomes or mediators/mechanisms of change (i.e., caregiver self-efficacy, outcome expectancies, behavioral capability, and environmental influence), we plan to conduct a cluster randomized controlled trial that randomly assigns group homes to experimental conditions within organizations. Outcomes will be measured at baseline, at post-implementation, and at a six-month follow-up. The control group will be implemented first over a nine-month period, followed by the intervention group over the same length of time. This will reduce contamination between the control and intervention group participants.

We estimate that approximately 80 group homes with an average of three caregivers and two to three adults with IDD must be recruited to obtain sufficient power to detect small- to medium-size effects. With such a large sample of group homes, we will need to implement the RCT in two cohorts with pairs of group homes matched and randomly assigned to control and experimental conditions within cohorts. Members of the research team have successfully used this research strategy in another large-scale NIH study .

The analysis of the anticipated larger RCT study will be more involved in both the process and outcome evaluations. For the process analysis (phase 7), we will produce frequency and percentages for all process measures. These results will be presented to an expert panel of 16 authors who have published implementation quality papers in order to assess the adequacy of the implementation quality of our larger study .Expert panels usually consist of a small number of members, which precludes performing inferential analyses from which inferences can be drawn . To increase our confidence in the results from our small sample of experts, we will analyze the observed data and then perform a bootstrap analysis . Using Excel, we will draw 1,000 bootstrapped samples of size 16, sampling with replacement, for each of our results. We will calculate average test values across all bootstrapped samples, except for p values that stem from the average t-statistic.

The outcome evaluation (phase 8) will produce outcome data for caregivers and adults with IDD nested in group homes. To answer research questions about intervention direct effects, we plan to use a three-level hierarchical linear model (HLM) random intercept regressions ,which will assess whether there have been differential changes between the intervention and control groups on proximal, intermediate, or distal outcomes. Hierarchical non-linear modeling (HNLM) will be used for dichotomous outcomes.

Phase 8 of the larger study analysis also concerns the assessment of mediating and moderating effects. We plan to use multilevel structural equation model (MSEM) procedures to determine whether social cognitive factors (e.g., caregiver self-efficacy) mediate the relationship between intervention exposure and intermediate and/or distal outcomes . MSEM solves for parameters at both an adult with IDD level and group home level, and constraints are placed across models to represent the effects of random variability.

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