社區(qū)資源互惠模式與運(yùn)作

1、社區(qū)資源互惠模式與運(yùn)作 Round table與談人張進(jìn)順 DDS, MPH, PhD.臺(tái)灣口腔衛(wèi)生學(xué)會(huì)理事長(zhǎng) 2009年臺(tái)灣健康促進(jìn)學(xué)校學(xué)術(shù)研討會(huì) 98/10/221產(chǎn)、官、學(xué)、社整合模式全民口腔衛(wèi)生運(yùn)動(dòng)舉辦全市美齒小姐選拔及 學(xué)童健牙活動(dòng) 基隆市國(guó)中、小學(xué)童B型肝炎篩選及流行病學(xué)調(diào)查與宣導(dǎo)大 型計(jì)劃(對(duì)象近六萬(wàn)名國(guó)中、小學(xué)童)基隆市四十歲以上婦女健康篩選與照顧計(jì)劃老人健康檢查與照顧計(jì)劃殘障者之健康檢查與照顧計(jì)劃養(yǎng)老、防老、尊老活動(dòng)及晨間社區(qū)衛(wèi)教計(jì)劃臺(tái)灣山地鄉(xiāng)口腔醫(yī)療保健服務(wù)計(jì)畫(huà) 青少年牙周疾病防治計(jì)畫(huà) 糖尿病共同照護(hù)網(wǎng)口腔健康照護(hù)計(jì)畫(huà)校牙醫(yī)師進(jìn)駐健促校園服務(wù)計(jì)畫(huà) 2成功推動(dòng)健康計(jì)畫(huà)之核心理

2、念與方法實(shí)踐渥太華憲章中健康促進(jìn)的五大行動(dòng)綱領(lǐng)實(shí)踐基本健康照護(hù)的四大執(zhí)行策略遵守實(shí)證基礎(chǔ)之有效介入措施整合口腔衛(wèi)生議題于一般衛(wèi)生計(jì)畫(huà)事前評(píng)估、事中監(jiān)測(cè)、事後評(píng)價(jià)3Ottawa Charter for Health Promotion WHO 1986Five action areas:Building healthy public policyCreating supportive environmentsStrengthening community actionDeveloping personal skillsRe-orientating health services Oral hea

3、lth promotion is defined as the use of these actions to pursue oral health goalsSprod et al 19964Implementation strategies of PHCIntersectoral CollaborationIntrasectoral CollaborationCommunity ParticipationPolitical SupportComprehensive primary oral health care Source: WHO, 19785Evidence-Based Oral

4、Health Promotion 表一6Evidence-Based Oral Health Promotion 表二策略健康影響實(shí)證的類(lèi)型潛在的健康獲益發(fā)展個(gè)人技能(Developing personal skills)口腔衛(wèi)生指導(dǎo)牙菌斑控制。(包 括使用牙間刷、牙線)對(duì)健康行為改變有影響力，以及牙周疾病的預(yù)防和控制I-至少一篇良好系統(tǒng)性回顧1-有利牙間刷牙周疾病的預(yù)防和控制I-至少一篇良好系統(tǒng)性回顧1-有利刷牙合併使用含氟牙膏齲齒的預(yù)防和控制I-至少一篇良好系統(tǒng)性回顧1-有利定期看牙醫(yī)在健康行為改變有影響力IV-設(shè)計(jì)良好的觀察性研究2-可能有利戒菸建議口腔癌的預(yù)防和控制I-至少一篇良好系統(tǒng)

5、性回顧1-有利飲食的建議在健康行為改變有影響力V-專(zhuān)家意見(jiàn)2-可能有利運(yùn)動(dòng)中護(hù)牙套防止口腔的創(chuàng)傷IV-設(shè)計(jì)良好的觀察性研究2-可能有利氟化物(自我使用，例如，含氟 漱口水，氟化物，氟錠，滴劑)齲齒的預(yù)防和控制I-至少一篇良好系統(tǒng)性回顧1-有利健康服務(wù)再次定向(Re-orientating health services)氟化物(例如使用氟膠，氟漆等 等)齲齒的預(yù)防和控制I-至少一篇良好系統(tǒng)性回顧1-有利使用溝隙封閉劑。 對(duì)易受影響的牙齒表面的耐酸黏 著的薄層應(yīng)用齲齒的預(yù)防和控制I-至少一篇良好系統(tǒng)性回顧1-有利牙結(jié)石清除牙周疾病的預(yù)防和控制I-至少一篇良好系統(tǒng)性回顧2-可能有利7Evidenc

6、e-based Effective Oral Health Interventions8Evidence base summary of oral health interventions (1) WHO, 2005TopicReferenceReview typeSummary findingsWater fluoridationSalt FluoridationLocker (1999) (10)McDonagh et al (2000) (11)Systematic reviewsLevel of Evidence I; Strength of Recommendation A. Qua

7、lity of studies low to moderateEstimated caries preventive effect 14% reductionEffect tends to be greatest in primary dentitionTopical fluoridesMarinho et al. (2002) (12)Marinho et al. (2002) (13)Marinho et al. (2003) (14)Marinho et al. (2003) (15)Marinho et al. (2003) (16)Marinho et al. (2004) (17)

8、Marinho et al. (2004) (18)Cochrane reviewsLevel of Evidence III; Strength of Recommendation A.Specific reductions in caries rates were estimated to be 24% for fluoride toothpaste, 26% for mouth rinses, 28% for gels and 46% for varnishes. Overall estimate of benefit was 26% in permanent dentition and

9、 33% in primary dentition9Evidence base summary of oral health interventions (2) WHO, 2005TopicReferenceReview typeSummary findingsFissure sealantsAhovuo-Saloranto et al. (2004) (19)Cochrane review; Level of Evidence I;Strength of Recommendation A.Caries reductions ranging from 86% at 12 months to 5

10、7% at 48 months were achieved. The level of effectiveness is dependent upon the baseline caries rateDental health educationBrown (1994) (20)Schou & Locker (1994) (21)Kay & Locker (1996) (22)Sprod et al. (1996) (23)Kay & Locker (1997) (24)Effectiveness reviewMajority of interventions health education

11、 in natureShort-term improvements in oral health knowledge achieved, but effects on behaviour and clinical outcomes limitedProvision of health information alone did not produce long-term behaviour changesSchool-based toothbrushing campaigns ineffective at improving oral hygieneNo evidence on effecti

12、veness of dietary intervention to reduce dental cariesMass media campaigns are ineffective at promoting either knowledge or behaviour changeStudy design and evaluation quality generally poor10Evidence base summary of oral health interventions (3) WHO, 2005TopicReferenceReview typeSummary findingsPer

13、iodontal healthWatt & Marinho (2005) (25)Systematic reviewInterventions all involved health educationShort-term reductions in plaque and gingival bleeding achieved in many studies. Clinical and public health significance of these changes questionableEvaluation quality generally poorScreening for ora

14、l cancerKujon et al. (2003) (26)Cochrane reviewsVery few high-quality studies were identifiedOne randomized controlled trial found no difference in age=standardized oral cancer mortality rates for screened groupNo evidence to support or refute the use of visual examination or other methods of screen

15、ing for oral cancer 11Evidence-Based Oral Health Promotion12EVIDENCE-BASED ORAL HEALTH PROMOTIONSTRATEGY HEALTH IMPACTSTYPE OF EVIDENCEBUILDING HEALTHY PUBLIC POLICYAdvocacyat all levelsCommunity awareness raisedExpert opinionCREATING SUPPORTIVE ENVIRONMENTSWater FluoridationSalt Fluoridation Preven

16、tion & control of cariesGood systematic Fluoride toothpastesreviewsSucrose substitutesPrevention & control of caries1 or more good RCTsAccess to Clinical ExamInfluences behavioral change Well-designed studies Use of workplaces etc toInfluences behavioral change1 or more RCTspromote & sustain good or

17、al healthSTRENGTHENING COMMUNITY ACTIONCommunity developmentInfluences behavioral changeExpert adviceGroup health education Influences behavioral change Observational studies(Primary health workers; and expert advicePre-school children & parents;Adolescents; Older persons)13EVIDENCE-BASED ORAL HEALT

18、H PROMOTIONSTRATEGY HEALTH IMPACTS TYPE OF EVIDENCEDEVELOPING OF PERSONAL SKILLSOral hygiene instruction Plaque control (inc. flossing) Health behavior change Good systematic reviews & prevention, control perio. Tooth brushing Prevention, control caries Good systematic reviews(with fluoride toothpas

19、te)Access to regular dental care Health behavior change Good observational studiesDietary advice Health behavior change Expert opinionSmoking cessation advice Prevention, control oral cancer Good systematic reviewsMouth guards Prevention oral trauma Good observational studiesRE-ORIENTATING HEALTH SERVICESFluorides (professionally applied) Pr