社区资源互惠模式与运作

1、社區資源互惠模式與運作 Round table與談人張進順 DDS, MPH, PhD.台灣口腔衛生學會理事長 2009年台灣健康促進學校學術研討會 98/10/221產、官、學、社整合模式全民口腔衛生運動舉辦全市美齒小姐選拔及 學童健牙活動 基隆市國中、小學童B型肝炎篩選及流行病學調查與宣導大 型計劃(對象近六萬名國中、小學童)基隆市四十歲以上婦女健康篩選與照顧計劃老人健康檢查與照顧計劃殘障者之健康檢查與照顧計劃養老、防老、尊老活動及晨間社區衛教計劃台灣山地鄉口腔醫療保健服務計畫 青少年牙周疾病防治計畫 糖尿病共同照護網口腔健康照護計畫校牙醫師進駐健促校園服務計畫 2成功推動健康計畫之核心理

2、念與方法實踐渥太華憲章中健康促進的五大行動綱領實踐基本健康照護的四大執行策略遵守實證基礎之有效介入措施整合口腔衛生議題于一般衛生計畫事前評估、事中監測、事後評價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證的類型潛在的健康獲益發展個人技能(Developing personal skills)口腔衛生指導牙菌斑控制。(包 括使用牙間刷、牙線)對健康行為改變有影響力，以及牙周疾病的預防和控制I-至少一篇良好系統性回顧1-有利牙間刷牙周疾病的預防和控制I-至少一篇良好系統性回顧1-有利刷牙合併使用含氟牙膏齲齒的預防和控制I-至少一篇良好系統性回顧1-有利定期看牙醫在健康行為改變有影響力IV-設計良好的觀察性研究2-可能有利戒菸建議口腔癌的預防和控制I-至少一篇良好系統

5、性回顧1-有利飲食的建議在健康行為改變有影響力V-專家意見2-可能有利運動中護牙套防止口腔的創傷IV-設計良好的觀察性研究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)齲齒的預防和控制I-至少一篇良好系統性回顧1-有利健康服務再次定向(Re-orientating health services)氟化物(例如使用氟膠，氟漆等 等)齲齒的預防和控制I-至少一篇良好系統性回顧1-有利使用溝隙封閉劑。 對易受影響的牙齒表面的耐酸黏 著的薄層應用齲齒的預防和控制I-至少一篇良好系統性回顧1-有利牙結石清除牙周疾病的預防和控制I-至少一篇良好系統性回顧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