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Background: Decision aids (DAs) have been proposed as tools to empower patients in decision‐making. However, implementing DA for decisions in advanced cancer is challenging. This study focuses on perspectives of oncologists and other healthcare providers on the hindering and facilitating factors for implementing a customizable DA. This DA is designed to support discussions about whether patients with advanced, incurable cancers should pursue or forgo further anticancer treatment. Methods: This qualitative study utilized content analysis following Sandelowski's approach on two different datasets derived from research projects on decision‐making in advanced cancer. To inform the development of a DA and understand challenges related to its implementation, we conducted semi‐structured interviews with 24 oncologists (Dataset 1) and three focus groups with various healthcare professionals (n = 19) and in addition post‐implementation semi‐structured interviews with oncologists who used the DA in conversations with their cancer patients (n = 5) (Dataset 2). Furthermore, the insights from process evaluation of developing and implementing the DA in an outpatients' settings was incorporated, enriching the analytical framework. Results: Two overall themes emerged: (1) Tension between standardizing the use of a DA and responding to individual patient needs. To address this conflict, a two‐part DA was developed, combining structured elements with flexibility. (2) Prerequisites for the use of the DA in outpatients' settings: Senior physicians' support, education in palliative care options and in the use of the DA, and organizational conditions. Conclusion: Oncologists identified both structural and content‐related aspects for a successful implementation of a DA for patients with advanced cancer. While the content‐related aspects were factored into the development of the DA, structural (organizational) issues need to be especially focused on during implementation. [ABSTRACT FROM AUTHOR]

Introduction: The impact of doula care on birth outcomes is well-established; however, doula support remains underutilized. Identifying barriers and facilitators to implementation is integral as the demand for doula care increases. The primary objective of this study was to examine doula program implementation across hospitals and payers at varying stages of implementation., Methods: Representatives from 4 hospitals and 2 payers participated in focus group discussions. The doula programs were categorized as anticipated, initial, and advanced implementation statuses. Coding and thematic analysis were conducted using a deductive application of the Consolidated Framework for Implementation Research., Results: There were 20 participants across 5 focus group discussions. Participants were mostly female, and nearly all had worked at their organization for at least 2 years. Salient themes shared across participants included valuing internal outcome data or peer-reviewed literature to support doula care as well as anecdotal stories; the reality of the resource-intensive nature of doula care implementation that goes beyond funding for doulas; and both the need for individual champions for change, such as midwives, and a supportive organizational culture that values health equity., Discussion: The findings of this study highlight 3 contextual aspects that should be considered when implementing doula programs. These recommendations include: (1) use of a combination of research evidence and anecdotes when eliciting stakeholder support; (2) consideration of resources beyond funding such as program implementation support; (3) critical evaluation of organizational culture as a primary driver influencing the implementation of doula care. The future of the doula workforce in United States hospitals rests on the crux of intentional buy-in from hospital administration and clinical providers as well as the availability of requisite resources., (© 2024 by the American College of Nurse‐Midwives.)

Integrating palliative care into the treatment of patients with advanced hematological malignancies (HM) remains challenging. To explore treating physicians' perspectives on current palliative care practice and to evaluate factors influencing integration, we conducted a nationwide online survey. Based on literature and expert review, the survey addressed the importance of palliative care, communication about life-threatening conditions, challenges in establishing goals of care, and factors influencing the integration of palliative care. 207 physicians treating patients with HM in Germany participated. We used standard descriptive statistics to analyze quantitative data and a content structuring approach. Most physicians considered palliative care in HM to be very important (60.6%) and discussed life-threatening conditions with more than half of their patients (52%), especially when goals of care were changed (87.0%) or when patients raised the topic (84.0%). Disease-related factors, different professional perspectives on prognosis, and patient hopes were the main barriers to changing goals of care, but collaboration with colleagues and multidisciplinary teams provided important support. Time constraints were identified as the main barrier to integrating palliative care. The majority worked well with palliative care teams. Referral processes and conditions were perceived as minor barriers. The study highlights the need to address barriers to integrating palliative care into the management of patients with advanced HM. Future research should aim at optimizing palliative care for patients with HM., (© 2024. The Author(s).)

Background: Palliative care (PC) contributes to improved end-of-life care for patients with hematologic malignancies (HM) and solid tumors (ST) by addressing physical and psychological symptoms and spiritual needs. Research on PC in HM vs. ST patients is fragmented and suggests less use., Methods: We analyzed claims data of all deceased members of a large German health insurance provider for the year before death. First, we analyzed the frequency and the beginning of different types of PC and compared patients with HM vs. ST. Second, we analyzed the adjusted impact of PC use on several end-of-life quality outcomes in patients with HM vs. ST. We performed simple and multiple (logistic) regression analysis, adjusted for relevant covariates, and standardized for age and sex., Results: Of the 222,493 deceased cancer patients from 2016 to 2020, we included 209,321 in the first analysis and 165,020 in the second analysis. Patients with HM vs. ST received PC less often (40.4 vs. 55.6%) and later (34 vs. 50 days before death). PC use significantly improved all six quality indicators for good end-of-life care. HM patients had worse rates in five of the six indicators compared with ST patients. Interaction terms revealed that patients with ST derived greater benefit from PC in five of six quality indicators than those with HM., Conclusion: The data highlight the need to integrate PC more often, earlier, and more effectively into the care of patients with HM., (© 2024. The Author(s).)

Research participation among vulnerable populations is often limited by the same socioeconomic factors that contribute to poor health. Identifying best practices for inclusion is critical to addressing health disparities. Urban public housing communities bear a disproportionate burden of chronic disease and may represent an opportunity to directly engage historically vulnerable populations in research designed to ultimately reduce that burden. We used mixed-method data to analyze recruitment effectiveness among a random sample of households (N = 380) across two public housing developments in Boston, MA who were approached for participation in a pre-COVID oral health study. Quantitative data from detailed recruitment tracking methods was analyzed to assess the relative efficiency of the methods employed. Field journals of study staff were qualitatively analyzed to identify community-specific recruitment barriers and facilitators. The participation rate among randomly sampled households was 28.6% (N = 131), with participation from primarily Hispanic (59.5%) or Black (26%) residents. Door-to-door knocking with response yielded the highest participation (44.8%), followed by responses to informational study flyers (31%). Primary barriers to enrollment included references to unemployment and employment variations, shift work, childcare responsibilities, time demands, and managing multiple appointments and social services. This study finds active, door-to-door knocking and return visits resolved barriers to participation, and reduced safety concerns and historic distrust. It's time to consider how best to adapt effective pre-COVID recruitment practices for utilization under current and future exposure conditions as effective recruitment of populations such as urban public housing residents into research is only becoming more important., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Patients with hematologic malignancies (HM) receive palliative care (PC) less often and later than patients with solid tumors (ST). Patients' lack of knowledge about PC and negative feelings about PC are barriers to their willingness to use PC. Is there a difference between patients with HM and ST in their knowledge and willingness to use PC?, Methods: Two hundred ten patients (85 HM, 125 ST) from an oncology day clinic at a university hospital participated in this cross-sectional, questionnaire-based survey., Results: Patients with HM and ST had high knowledge and mainly positive feelings about PC. More than half of the patients answered that they would feel reassured by the use of PC, and one-third would feel anxious or hopeless. The majority of patients (58.3%) were willing to use PC. There are no significant differences between patients with HM and ST. In multiple regression analysis, perceived chance of cure and feelings of reassurance and anxiety are associated with willingness to use PC, but not with the HM/ST disease group. More than half (53.9%) of the participants would like the treating physician to choose the timing of a discussion about PC., Conclusion: Our study shows a high level of knowledge and relatively positive feelings of patients about PC, with no differences between patients with HM or ST. They expect their treating physician to initiate communication about PC. Communication should include the patient's feelings about PC and their chances of a cure., (© 2023. The Author(s).)

Background: As awareness of perinatal health disparities grows, many birthing people of color are seeking racially and/or culturally concordant providers. We described preferences for, and perceptions of, racial and/or cultural concordance and cultural competence in the context of the doula-client relationship., Methods: Seven focus group discussions (FGDs) with a total of 27 participants were conducted to investigate the perspectives of patients and doulas across Massachusetts, United States. An interdisciplinary stakeholder group informed the data collection instrument content and design. Two coders achieved 0.89 Kappa for inter-rater reliability prior to coding the remaining transcripts. We used a modified grounded theory approach and Dedoose software for coding., Results: Two major themes emerged. First, cultural competency in doula care is a learning process, with definitions consistent with terms such as "cultural humility" and "structural competency." Doulas discussed listening to clients' needs rather than making assumptions, the importance of understanding privilege and power dynamics, and self-initiating relevant education beyond formal doula training. Second, trust was most frequently cited as an indicator of successful doula-patient relationships., Conclusions: Most study participants specified the importance of cultural humility in doula-client relationships. Doulas approaching the relationship humbly with a willingness to learn and challenge their own assumptions-regardless of the level of concordance-can make a meaningful impact on the perinatal experience., (© 2022 Wiley Periodicals LLC.)

Background: In Germany, palliative care (PC) is provided on a homecare, inpatient, general, and specialized basis. Since little is currently known about the temporal course and regional differences in the forms of care, the present study was aimed to investigate this., Method: In a retrospective routine data study with 417,405 BARMER-insured persons who died between 2016 and 2019, we determined the utilization rates of primary PC (PPC), specially qualified and coordinated palliative homecare (PPC+), specialized palliative homecare (SPHC), inpatient PC, and hospice care on the basis of services billed at least once in the last year of life. We calculated time trends and regional variability and controlled for needs-related patient characteristics and access-related county of community characteristics., Results: From 2016 to 2019, total PC increased from 33.8 to 36.2%, SPHC from 13.3 to 16.0% (max: Rhineland-Palatinate), and inpatient PC from 8.9 to 9.9% (max: Thuringia). PPC decreased from 25.8 to 23.9% (min: Brandenburg) and PPC+ came in at 4.4% (max: Saarland) in 2019. Hospice care remained constant at 3.4%. Regional variability in utilization rates remained high, increased for PPC and inpatient PC from 2016 to 2019, and decreased for SPHC and hospice care. The regional differences were also evident after adjustment., Conclusion: Increasingly more SPHC, less PPC, and high regional variability, which cannot be explained by demand- or access-related characteristics, indicate that the use of PC forms is oriented less to demand than to regionally available care capacities. In view of the growing need for palliative care due to demographic factors and decreasing personnel resources, this development must be viewed critically., (© 2023. The Author(s).)

Objectives  The aim of this study was to explore the impact of the COVID-19 pandemic and the efforts taken to contain it on specialized palliative homecare (SPHC) practice from the perspective of SPHC team leaders.Methods  In this cross-sectional study, an online questionnaire with quantitative and qualitative questions was developed and used, focusing on the experience of SAPV in the first and second wave of the COVID-19 pandemic in Germany. In a structured recruitment process, all German SPHC teams (n=357) were invited to participate. Results  From 10/10/2020 to 07/01/2021, 154 SPHC teams participated (response rate 43%). They described clear effects of the COVID-19 pandemic on their activities. Despite pandemic-related problems with staff availability (78.5%), patient care was ensured without major problems. The number of patients to be cared for remained stable for most teams, was increasing for some, and decreasing only for a few. A central factor was the switch from direct contact with patients and their relatives to telephone contact. Additional complicating factors were the general avoidance of contacts, compliance with hygiene regulations for necessary personal contacts, and pandemic-related uncertainties and fears, both among the team itself and among relatives and patients. The procurement of protective equipment was a challenge during the first wave. Problems in collaboration with network partners (e. g., nursing homes and volunteer hospice services) had decreased over the course of the pandemic, but were greater than before in all areas. Many measures to cope with the pandemic challenges were implemented, others were assessed as useful but not implemented, and others as not useful or feasible. Conclusions  SPHC teams report that despite the need to adapt many processes to the pandemic situation, they have managed to maintain patient care, although under more difficult conditions., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenskonflikt besteht., (Thieme. All rights reserved.)

Background: The COVID-19 pandemic confronted nursing homes with a variety of challenges to ensure the provision of palliative care for residents. PallPan-Implement aimed to adapt the recommendations of the National Strategy for the Care of Seriously Ill, Dying Adults and their Families in Times of Pandemic (PALLPAN) in such a way that nursing facilities can use and implement them., Methods: Based on 33 PALLPAN recommendations, we developed a questionnaire, conducted a pilot implementation for selected nursing homes, and asked for qualitative feedback., Results: The developed questionnaire contains 22 main questions. A three-stage pilot implementation with an introductory event, processing phase, and evaluation event took place in seven facilities. The facilities evaluated the developed questionnaire as helpful. Feedback from the facilities identified three major categories: (a) requirements for facilities should be realistic to avoid frustration, (b) the creation of a pandemic plan for palliative care only is impractical, (c) measures for the psychosocial support of staff is particularly necessary, but was perceived as difficult to implement., Conclusions: The practical implementation of recommendations requires a concept and material tailored to facilities and areas. The strategy of PallPan Implement developed in this project appears to be target-oriented, well-received, and can be recommended for further implementation.

Introduction: Since 2007, patients receiving palliative care have been entitled to specialised outpatient palliative care (SAPV). Until now, the quality of care of the SAPV was only regionally focussed or in relation to individual SAPV teams. A nationwide analysis of outcome quality is still awaited. The organisation and design of structures and processes vary greatly from region to region, which complicates a comparative assessment of implementation. One way to measure the quality of the heterogeneous structures and processes is to collect patient-reported outcomes. Here, it is possible to use symptom burden, quality of care and patient satisfaction with SAPV care, since patients' quality of life is a central focus of SAPV care. This article is part of the research project SAVOIR, which is funded by the G-BA Innovation Fund., Methods: For this prospective longitudinal survey of the outcome quality of SAPV, structured data were collected at two measurement points (t 1 and t 2 [4-10 days after t 1 ]). A nationwide, representative sample of SAPV teams was targeted. These teams performed consecutive recruitment of patients included in SAPV. Two questionnaire instruments were used: the IPOS (Integrated Palliative Outcome Scale) at t 1 and t 2 , and the QUAPS (quality control in specialized palliative home care) questionnaire at t 2 . Patient-reported outcomes measured improvement in symptom burden, patient satisfaction, and quality of care from the patient perspective. In addition, an exploratory stepwise regression analysis of factors associated with satisfaction was conducted., Results: 42 SAPV teams agreed to participate in the study. They recruited a total of 964 patients at measurement time t 1 (t 2 : 690 patients). The analyses show that the number and intensity of symptoms from the patient perspective decreased significantly during the course of SAPV treatment, especially pain, gastrointestinal symptoms, but also psychological complaints. 74.7 % of the patients reported a high level of satisfaction with SAPV. Also, the quality of care was considered to be high by the patients. Exploratively, five factors were extracted that explain 55 % of the satisfaction with SAPV: respect for the patient's decision, quality of communication, support with practical problems, and referral to care measures as well as symptom relief between the two measurement points., Conclusions: The SAPV patients recruited from a total of nine KV regions reported a reduced symptom burden and a high level of satisfaction with SAPV and rated the quality of care provided by SAPV as high., (Copyright © 2022. Published by Elsevier GmbH.)

Background: The COVID-19 pandemic has affected health care systems worldwide. Multidisciplinary teams provide specialist palliative home care (SPHC) for patients with incurable, severe, progressive diseases. These patients are at the same time at high risk, if infected, highly constricted by containment measures, and dependent on support., Aim: To explore i) how German SPHC teams were affected by the pandemic during the first wave, ii) which challenges they faced, and iii) which strategies helped to handle the consequences of the COVID-19 pandemic for providing good SPHC., Method: Four focus groups (with representatives of 18 SPHC teams) and five guided interviews with stakeholders were conducted and analysed using qualitative content analysis., Results: Seven key categories emerged from the data. A category in the background describes dependence on organizational characteristics (e.g. sponsorship), which varied by regional factors. Information management was a challenge to SPHC teams, as they had to collect, interpret and adapt, and disseminate information. They reported a shift in patient care because of the COVID-19 pandemic, due to restricted home visits, visitation ban in nursing homes, and difficulties for hospital, hospice and nursing home admissions. Measures to reduce risk of infection impeded teamwork. Teams relied upon their local networks in crisis management, but felt often overlooked by local health authorities. Their respective SPHC state associations supported them in information management and exchange., Discussion: The pandemic has severely impacted home care for especially vulnerable seriously ill and dying people. A good network with local health providers and authorities could help to harmonize local regulations and ensure quality care for all patient groups. SPHC teams could play an important role in caring for palliative patients with COVID-19 who are not admitted to a hospital due to preferences or resources., Competing Interests: The authors have declared that no competing interests exist.

Background: Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care., Methods: We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility., Findings: Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences., Conclusions: The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media., (Copyright © 2021. Published by Elsevier Inc.)

The American Association for Dental Research (AADR) is committed to providing a collegial, safe, and welcoming environment for all. As part of this effort, we assessed perceptions and experiences related to sexual, gender-based, and non-gender-based harassment among registrants at AADR annual meetings from 2015 to 2018 ( n = 10,495); examined demographic factors associated with reported experiences; and identified facilitators and potential solutions concerning these types of harassment. Registrants were emailed an invitation to an anonymous online survey. Demographics were assessed categorically, and response distributions to close-ended survey items were evaluated by these variables. Bivariate analyses of participant demographics were conducted with 8 types of perceived harassment. To determine the demographic distribution of reporters, along with bivariate associations among them, restricted analyses were performed among individuals reporting any type of harassment. Qualitative data analysts conducted content analysis of the open-ended responses to questions asking participants to reflect on the topic. Peer debriefing was used to refine the coding schema. A total of 824 responses were received, of which 172 individuals reported experiencing ≥1 of the 8 types of harassment surveyed. Among those, reports of condescending remarks occurred most frequently (70%). Reported harassment of a more sexual nature was less common by comparison. Reporters of harassment were more likely to be women, members of the AADR/CADR (Canadian Association for Dental Research) divisions, and/or frequent meeting attendees. A total of 229 respondents answered at least 1 of the open-ended questions. While the majority of survey respondents reported no personal experience with harassment at AADR meetings, the fact that 1 in 5 did should be cause for concern. In 2018, AADR introduced a "Professional Conduct at Meetings Policy" delineating unacceptable behaviors, including intimidating or harassing speech and actions. Results of this survey form an important baseline from which its impact may be monitored to ensure that future AADR meetings are respectful, supportive, and safe environments for all.

Introduction: We conducted a qualitative analysis to evaluate the acceptability of using storytelling as a way to communicate oral health messages regarding early childhood caries (ECC) prevention in the American Indian and Alaska Native (AIAN) population., Methods: A traditional story was developed and pilot tested among AIAN mothers residing in 3 tribal locations in northern California. Evaluations of the story content and acceptability followed a multistep process consisting of initial feedback from 4 key informants, a focus group of 7 AIAN mothers, and feedback from the Community Advisory Board. Upon story approval, 9 additional focus group sessions (N = 53 participants) were held with AIAN mothers following an oral telling of the story., Results: Participants reported that the story was culturally appropriate and used relatable characters. Messages about oral health were considered to be valuable. Concerns arose about the oral-only delivery of the story, story content, length, story messages that conflicted with normative community values, and the intent to target audiences. Feedback by focus group participants raised some doubts about the relevance and frequency of storytelling in AIAN communities today., Conclusion: AIAN communities value the need for oral health messaging for community members. However, the acceptability of storytelling as a method for the messaging raises concerns, because the influence of modern technology and digital communications may weaken the acceptability of the oral tradition. Careful attention must be made to the delivery mode, content, and targeting with continual iterative feedback from community members to make these messages engaging, appropriate, relatable, and inclusive.

Objectives: To identify successful strategies for retention of participants in multiyear, community-based randomized controlled trials (RCTs) aiming to reduce early childhood caries in health disparities populations from diverse racial/ethnic backgrounds and across diverse geographic settings., Methods: Four RCTs conducted by the Early Childhood Caries Collaborating Centers (EC4), an initiative of the National Institute of Dental and Craniofacial Research, systematically collected information on the success of various strategies implemented to promote participant retention in each RCT. The observational findings from this case series of four RCTs were tabulated and the strategies rated by study staff., Results: Participant retention at 12 months of follow-up ranged from 52.8 percent to 91.7 percent, and at 24 months ranged from 53.6 percent to 85.9, across the four RCTs. For the three RCTs that had a 36-month follow-up, retention ranged from 53.6 percent to 85.1 percent. Effectiveness of different participant retention strategies varied widely across the RCTs., Conclusions: Findings from this case series study may help to guide the design of future RCTs to maximize retention of study participants and yield needed data on effective interventions to reduce oral health disparities., (© 2016 American Association of Public Health Dentistry.)

Objectives: To explore the opportunities for interprofessional collaboration (IPC) to improve paediatric oral health in federally qualified health centres (FQHCs), to identify challenges to IPC-led integration of oral health prevention into the well-child visit and to suggest strategies to overcome barriers., Sample: Nurse managers (NMs), nurse practitioners (NPs), paediatric clinical staff and administrators in six FQHCs in two states were interviewed using a semistructured format., Design: Grounded theory research. Topics included feasibility of integration, perceived barriers and strategies for incorporating oral health into paediatric primary care., Measurements: Qualitative data were coded and analysed using NVivo 10 to generate themes iteratively., Results: Nurses in diverse roles recognised the importance of oral health prevention but were unaware of professional guidelines for incorporating oral health into paediatric encounters. They valued collaborative care, specifically internal communication, joint initiatives and training and partnering with dental schools or community dental practices. Barriers to IPC included inadequate training, few opportunities for cross-communication and absence of charting templates in electronic health records., Conclusions: NMs, NPs and paediatric nursing staff all value IPC to improve patients' oral health, yet are constrained by lack of oral health training and supportive charting and referral systems. With supports, they are willing to take on responsibility for introducing oral health preventive measures into the well-child visit, but will require IPC approaches to training and systems changes. IPC teams in the health centre setting can work together, if policy and administrative supports are in place, to provide oral health assessments, education, fluoride varnish application and dental referrals, decrease the prevalence of early childhood caries and increase access to a dental home for low-income children., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Introduction: Early childhood caries, the most common chronic childhood disease, affects primary dentition and can impair eating, sleeping, and school performance. The disease is most prevalent among vulnerable populations with limited access to pediatric dental services. These same children generally receive well-child care at federally qualified health centers. The objective of this study was to identify facilitators and barriers to the integration of oral health into pediatric primary care at health centers to improve problem recognition, delivery of preventive measures, and referral to a dentist., Methods: We collected and analyzed background data and data from structured observations and 39 interviews with administrators and staff at 6 clinics in 2 states, Maryland and Massachusetts., Results: Participants valued oral health across professional roles but cited limited time, lack of training and expertise, low caregiver literacy, and lack of shared medical and dental electronic records as barriers to cooperation. Facilitators included an upper-level administration with the vision to see the value of integration, designated team leaders, and champions. An administration's vision, not structural determinants, patient characteristics, or geographic location, predicted the level of integration. Interviewees generated multilevel recommendations to promote delivery of oral health preventive measures and services during a well-child visit., Conclusion: Poor oral health contributes to health care disparities. Barriers to integrating dental care into pediatric medical practice at health centers must be overcome to improve oral health for children living in poverty, with a disability, at a rural address, or any combination of these. Implementation will require adapting delivery systems to support multidisciplinary collaboration. Strategies suggested here may point the way to enhancing children's oral health.