Defining quality of preventive oral health services in a northern First Nations community: a concept mapping study.

INTRODUCTION: In partnership with the Norway House Cree Nation (NHCN) in Manitoba, Canada, this study developed a framework based on how Indigenous parents/caregivers of young children and community-based oral health decision-makers perceive 'quality of preventive oral health services'. METHODS: Concept mapping was used to develop the 'quality of preventive oral health services' framework. This involved brainstorming/idea generation, sorting and rating, visual representation, and interpretation sessions with parents/caregivers (CG) and decision-makers (DM) in Norway House, Manitoba. Using the Concept System's GlobalMax software, a conceptual framework was created that was modified from input from CG and DM groups, which can be visualized through the concept map. RESULTS: The final concept map revealed seven domains of quality preventive oral health services: dental staff character and skills, working with community, responsibilities in preventive education, inclusive preventive oral health strategies, accessibility to appointments, logistics of providing services, and dental environment. CONCLUSION: This study provides insight into the existing gap in oral health services for Indigenous populations. Based on conversations and the concept mapping process, the developed framework can inform the steps to be taken to improve preventive oral health services for Indigenous peoples. The framework has been used to develop a quantitative scale to inform sustainable and impactful change in the quality of preventive oral health services that are meaningful to Indigenous peoples.

Building effective public dental care programs: The critical role of implementation evaluation.

There are significant income-related inequities in oral health and access to oral health care. Public dental programs generally aim to increase access to oral health care for individuals with financial barriers through government payments for appointments. Low engagement from both oral health care providers and intended patients are common challenges in delivery of public dental programs, and are impediments to program impact and outcomes. Still, these programs rarely address the systemic issues that affect the experiences of intended users. This accentuates the importance of monitoring of program delivery to refine or adapt programs to better meet needs of service providers and users. As such, specifying program goals and developing a related monitoring strategy are critical as Canada begins to implement a national public dental program. Drawing on an example of a pediatric public dental program for children from low-income families or with severe disabilities in Ontario, Canada, this article illustrates how an implementation and evaluation framework could be applied to measure implementation and impact of the national program. The RE-AIM framework measures performance across five domains: (1) Reach, (2) Effectiveness (patient level), (3) Adoption, (4) Implementation (provider, setting, and policy levels), and (5) Maintenance (all levels). Given the disparities in oral disease and access to oral health care, the results can be used most effectively to adapt programs if relevant stakeholders participate in reviewing data, investigating quality gaps, and developing improvement strategies.

Clinical performance of CAD-CAM crowns provided by predoctoral students at the University of Toronto.

STATEMENT OF PROBLEM: The clinical success of monolithic lithium disilicate glass-ceramic (LDGC) crowns manufactured with computer-aided design and computer-aided manufacturing (CAD-CAM) technology provided by predoctoral students has not been fully investigated. PURPOSE: The purpose of this retrospective clinical study was to evaluate the performance of laboratory-fabricated monolithic posterior LDGC CAD-CAM crowns provided by predoctoral students at the University of Toronto. Specific patient- and provider-related factors were also investigated. MATERIAL AND METHODS: A sample of posterior LDGC CAD-CAM crowns (IPS e.max) provided by predoctoral students was evaluated. Crown preparations were made according to specific criteria, and crowns were milled in an in-house laboratory by using the CEREC Bluecam system. The crowns were cemented with Rely-X Unicem (3M ESPE) and Calibra Universal (Dentsply Sirona) resin cements. Clinical assessments of the crowns and supporting periodontal structures were performed following the modified California Dental Association (CDA) criteria. Intraoral photographs and periapical and bitewing radiographs were obtained for further assessment by 2 evaluators. Descriptive statistics, McNemar, t test, log rank (Mantel-Cox) tests, Pearson chi-squared tests, simple logistic regression, odds ratios, and Kaplan Meier survival analyses were performed (α=.05). RESULTS: A total of 189 patients receiving 210 crowns (108 premolar and 102 molar) were examined with a follow-up period of up to 6 years. Altogether, 28 complications were observed (12 technical, 11 biological, and 5 esthetic). No significant association was found between patient age, sex, periodontal condition, tooth type, tooth vitality, cement type, and crown longevity. However, significantly lower survival and success rates were found for mandibular crowns than for maxillary crowns (P=.029). The provider's experience had no significant effect on the clinical performance of LDGC CAD-CAM crowns. The 6-year cumulative survival rate was 93.0%, and the success rate was 86.4%. CONCLUSIONS: The ease of use of the CAD-CAM system and clinical performance of LDGC suggest that this technology should be used in the dental school setting by predoctoral students.

Association between psychosocial determinants of adverse childhood experiences and severe early childhood caries among First Nations children.

AIM: To determine whether psychosocial determinants of adverse childhood experiences (ACE), from pregnancy to 2 years old, are associated with severe early childhood caries (S-ECC) in Indigenous children. DESIGN: Secondary data analyses from an ECC prevention trial among 344 First Nations mother-child dyads living on- and off-reserve in Ontario and Manitoba, Canada. Stratified (on-/off-reserve) logistic regression, controlling for mother's age and income source, assessed three categories of psychosocial ACE determinants: alcohol/drug misuse, household financial hardship (overcrowding and food insecurity) and emotional/social well-being (Perceived Stress Scale (PSS-14), sense of personal control (SOC), social support, subjective social status). RESULTS: Household overcrowding [adjusted odds ratio (AOR) = 1.89 (95% CI: 1.06-3.38)], food insecurity [AOR = 2.86 (1.53-5.34)] and mothers' high perceived stress [AOR = 2.48 (1.40-4.37)] were associated with S-ECC (dmft > 9) for those on-reserve. Maternal SOC had a protective effect for off-reserve children [AOR = 0.17 (0.03-0.95)]. CONCLUSIONS: Increased efforts to reduce psychosocial ACE determinants are paramount to decreasing Indigenous children's vulnerability to S-ECC.

Advancing Our Understanding of Dental Care Pathways of Refugees and Asylum Seekers in Canada: A Qualitative Study.

The burden of oral diseases and need for dental care are high among refugees and asylum seekers (humanitarian migrants). Canada's Interim Federal Health Program (IFHP) provides humanitarian migrants with limited dental services; however, this program has seen several fluctuations over the past decade. An earlier study on the experiences of humanitarian migrants in Quebec, Canada, developed the dental care pathways of humanitarian migrants model, which describes the care-seeking processes that humanitarian migrants follow; further, this study documented shortfalls in IFHP coverage. The current qualitative study tests the pathway model in another Canadian province. We purposefully recruited 27 humanitarian migrants from 13 countries in four global regions, between April and December 2019, in two Ontario cities (Toronto and Ottawa). Four focus group discussions were facilitated in English, Arabic, Spanish, and Dari. Analysis revealed barriers to care similar to the Quebec study: Waiting time, financial, and language barriers. Further, participants were unsatisfied with the IFHP's benefits package. Our data produced two new pathways for the model: transnational dental care and self-medication. In conclusion, the dental care needs of humanitarian migrants are not currently being met in Canada, forcing participants to resort to alternative pathways outside the conventional dental care system.

Correction: What influences the clinical decision-making of dentists? A cross-sectional study.

[This corrects the article DOI: 10.1371/journal.pone.0233652.].

The impact of oral health education taken by personal support workers caring for a geriatric population in a long-term care facility: A mixed-methods study.

OBJECTIVE: To evaluate the impact of an online oral health education module on personal support workers' (PSW) knowledge and beliefs in their care for long-term care (LTC) residents in one Canadian LTC residence. BACKGROUND: LTC residents are dependent on PSWs for their oral health needs. However, PSWs receive minimal to no oral health education placing residents at risk for poor oral health. METHODS: A mixed-methods convergent design comprising a before-and-after questionnaire (N = 88), focus groups (N = 23) and interviews (N = 4) exploring module learning. Analysis of each data set was followed by their amalgamation and comparison. RESULTS: The online module had limited impact on the PSWs' knowledge and beliefs regarding resident oral health care. The quantitative results demonstrated knowledge improvements in two domains and changes in two belief domains. However, the qualitative results demonstrated new knowledge was not developed or sustained in practice. Themes that emerged include the following: lack of module recall, unmet learning needs and methods for oral care delivery, and timing of oral care in a busy clinical environment. CONCLUSION: Online oral health education alone has limited impact on PSWs' knowledge and beliefs. Research evaluating multifaceted education interventions including hands-on training with a dental expert is warranted.

What influences the clinical decision-making of dentists? A cross-sectional study.

Clinical decision-making is a complex process influenced by clinical and non-clinical factors. The aim of this study was to investigate the association between provider, patient, and practice factors with clinical decision-making among dentists in Ontario, Canada's most populated province and its largest dental care market. This was a cross-sectional, self-administered survey of a random sample of general dentists in Ontario (n = 3,201). The 46-item survey collected demographic, professional, and practice information. The outcome (treatment intensity) was measured using a set of clinical scenarios, which categorized dentists as either relatively aggressive or conservative in their treatment decisions. Associations were assessed using bivariate analysis and logistic regressions. One thousand and seventy-five dentists responded (33.6% response rate). Age (p = 0.001), place of initial training (p<0.001), number of dependents (p = 0.001), number of hygienists employed (p = 0.001), and perceptions of practice loans (p = 0.020) were associated with treatment intensity. Dentists who were <40-years old (OR = 2.06, 95% CI:1.39-3.06, p<0.001), American-trained (OR = 2.48, 95% CI:1.51-4.06, p<0.001), and perceived their practice loans as large (OR = 1.57, 95% CI:1.02-2.42, p = 0.039), were relatively more aggressive in their treatment decisions. Various non-clinical factors appear to influence the clinical decision-making of dentists in Ontario.

Does competition affect the clinical decision-making of dentists? A geospatial analysis.

OBJECTIVES: To investigate the association between dentists' geographic density and perceptions of market competition with clinical decision-making among a representative sample of dentists in Ontario, Canada's most populated province. METHODS: Competition was quantified using dentist density, defined as the number of dental clinics lying within a one kilometre radius around the respondents' clinic address and by self-reported perceived pressure from other dental clinics. The outcome (clinical decision-making or treatment intensity) was measured using a set of clinical scenarios, which categorized dentists as either relatively aggressive or conservative. Associations were assessed using bivariate analysis and logistic and linear regression. RESULTS: Dentists who perceived large competitive pressure from other dentists (OR = 1.63, 95% CI: 1.07-2.49) were relatively more aggressive in their treatment choices. Interestingly, dentists located in very low dentist density areas (OR = 1.31, 95% CI: 1.03-1.68) were also relatively more aggressive in their treatment choices. CONCLUSION: This study is the first to explore the impact of competition on the clinical decision-making of dentists in a Canadian context. It presents a valuable addition to the competition literature and helps to understand current dynamics in the Canadian dental care market.

Perceived professional roles and implications for clinical decision-making.

OBJECTIVES: This study aims to (a) investigate the relationship between dentists' perceived professional role (PPR), defined as the belief that they are health care professionals versus business people, and treatment intensity, determined by the aggressiveness of clinical approaches, such as in number or scope, and (b) identify the demographic and practice characteristics that have a relationship to PPR. METHODS: A 46-item survey with questions on dentists' demographic and professional characteristics was mailed to a random sample of 3,201 general dentists in Ontario, Canada. PPR was measured by visual analog scale and by Likert-type scale questions, which have been validated in the literature in terms of their ability to measure PPR. Treatment intensity was measured by a set of case scenarios. Univariate, bivariate, and multivariable analyses were performed. RESULTS: One-thousand and seventy-five dentists returned usable surveys (33.6% response rate). When using the two methods to measure PPR, visual analog scale and Likert-type scale questions, dentists who identified as business people tended to have a higher treatment intensity compared to those who identified as health care professionals (p < 0.1 and p < 0.05, respectively). In multivariable logistic regression, years of practice, number of technologies used in a practice, and perceiving other dentists as competitors rather than colleagues were significant predictors of identifying as a business person. CONCLUSIONS: Dentists' PPRs had a significant relationship to the aggressiveness of treatment decisions. Demographic and practice characteristics also had significant relationships to PPR. These findings may have implications for public trust and dentistry's status as a health care profession.

Clinical performance of chairside monolithic lithium disilicate glass-ceramic CAD-CAM crowns.

OBJECTIVES: To evaluate the clinical performance and the effect of various patient and provider-related factors on the longevity of chairside monolithic posterior lithium disilicate glass-ceramic (LDGC) computer-aided design (CAD)-computer-aided manufacturing (CAM) crowns provided by predoctoral students. MATERIALS AND METHODS: A sample of posterior LDGC CAD-CAM crowns was evaluated. Crown preparations were milled chairside using the CEREC Omnicam system and cemented with Rely-X Unicem or Calibra Universal resin cements. Clinical assessment of the crowns and supporting periodontal structures was performed using the modified California Dental Association (CDA) criteria. Intraoral photographs as well as radiographs were taken for further assessment by two evaluators. Kaplan-Meier survival analysis was performed. RESULTS: A total of 40 crowns were inserted in 32 patients and evaluated for 4 years. Three complications were observed (two-technical and one-biological). No chipping or fracture of crowns was observed. No significant association was found between age, sex, periodontal condition, tooth type, tooth vitality, cement type, and longevity. The 4-year cumulative survival and success rates were 95.0 and 92.3%, respectively. CONCLUSION: Chairside LDGC CAD-CAM crowns exhibited a high survival rate after 4 years in function and were shown to be a viable and reliable treatment option for posterior teeth. CLINICAL SIGNIFICANCE: The high survival rate of chairside CAD-CAM crowns observed in this study suggests the likelihood of predictable performance in the predoctoral setup.

Follow-up of an Intervention to Reduce Dental Caries in Indigenous Australian Children: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Testing the long-term usefulness of a childhood intervention and determining the best age of implementation are important for translation and policy change. Objectives: To investigate among children aged 3 years the long-term effectiveness an intervention that aimed to reduce dental caries among South Australian Aboriginal children and to assess if children in the delayed intervention (DI) group had any benefit from the intervention from ages 2 to 3 years and if the intervention usefulness was greater when delivered between pregnancy and age 2 years (immediate intervention [II] vs ages 2 to 3 years [DI]). Design, Setting, and Participants: Secondary analysis of a randomized clinical trial. The study enrolled 448 pregnant women across South Australia, Australia, at baseline (February 1, 2011, to May 30, 2012), with 223 randomly allocated to the II group and 225 to the DI group. Three-year follow-up data were collected November 2014 to February 2016. Interventions: The intervention comprised dental treatment to mothers, fluoride varnish application to children, and motivational interviewing delivered together with anticipatory guidance. This was delivered during pregnancy and at child ages 6, 12, and 18 months for the II group and at child ages 24, 30, and 36 months for the DI group. Main Outcomes and Measures: The mean number of decayed teeth measured at child age 3 years. Results: There were 324 children at age 3 years (52.3% male). The mean number of decayed teeth at age 3 years was 1.44 (95% CI, 1.38-1.50) for the II group and 1.86 (95% CI, 1.89-2.03) for the DI group (mean difference, -0.41; 95% CI, -0.52 to -0.10). The predicted mean number of decayed teeth at age 3 years for the DI group was 2.15. Between ages 2 and 3 years, the caries increment for the II group was 0.82 (95% CI, 0.75-0.89), compared with 0.97 (95% CI, 0.87-1.17) for the DI group (P = .05). Conclusions and Relevance: At the 3-year follow-up, II children had less dental caries than DI children, DI children developed dental caries at a lower trajectory than predicted had the intervention not been received at ages 2 to 3 years, and the caries increment was less between ages 2 to 3 years among II children compared with DI children. This study suggests that the best time to implement the intervention is earlier rather than later infancy. Trial Registration: Australian and New Zealand Clinical Trial Registry Ideintifier: ACTRN12611000111976.

The Oral Health of Refugees and Asylum Seekers in Canada: A Mixed Methods Study Protocol.

Canada received over 140,000 refugees and asylum seekers between 2015 and 2017. This paper presents a protocol with the purpose of generating robust baseline data on the oral health of this population and build a long-term program of research to improve their access to dental care in Canada. The three-phase project uses a sequential mixed methods design, with the Behavioral Model for Vulnerable Populations as the conceptual framework. In Phase 1a, we will conduct five focus groups (six to eight participants per group) in community organizations in Ontario, Canada, to collect additional sociocultural data for the research program. In Phase 1b, we will use respondent-driven sampling to recruit 420 humanitarian migrants in Ontario and Quebec. Participants will complete a questionnaire capturing socio-demographic information, perceived general health, diet, smoking, oral care habits, oral symptoms, and satisfaction with oral health. They will then undergo dental examination for caries experience, periodontal health, oral pain, and traumatic dental injuries. In Phase 2, we will bring together all qualitative and quantitative results by means of a mixed methods matrix. Finally, in Phase 3, we will hold a one-day meeting with policy makers, dentists, and community leaders to refine interpretations and begin designing future oral health interventions for this population.

Dental Disease Outcomes Following a 2-Year Oral Health Promotion Program for Australian Aboriginal Children and Their Families: A 2-Arm Parallel, Single-blind, Randomised Controlled Trial.

BACKGROUND: Dental disease has far-reaching impacts on child health and wellbeing. We worked with Aboriginal Australian communities to develop a multifaceted oral health promotion initiative to reduce children's experience of dental disease at age 2 years. METHODS: This was a single-blind, parallel-arm, randomised controlled trial. Participants were recruited from health service providers across South Australia. Women pregnant with an Aboriginal child were eligible. The intervention comprised: (1) provision of dental care to mothers during pregnancy; (2) application of fluoride varnish to teeth of children at ages 6, 12 and 18 months; (3) motivational interviewing delivered in conjunction with; (4) anticipatory guidance. The primary outcome was untreated dental decay as assessed by the number of teeth with cavitated and non-cavitated carious lesions (mean dt) at child age 24 months. Analyses followed intention-to-treat principles. The RCT was registered with the Australian and New Zealand Clinical Trial Registry, ACTRN12611000111976. FINDINGS: Women (n = 448) were recruited from February 2011 to May 2012, resulting in 223 children in the treatment group and 225 in the control. Mean dt at age two years was 0.62 (95% CI 0.59 to 0.65) for the intervention group and 0.89 (95% CI 0.85 to 0.92) for the control group (mean difference - 0.27 (95% CI - 0.31, - 0.22)). INTERPRETATION: A culturally-appropriate intervention at four time-points from pregnancy through to 18-months resulted in improvements in the oral health of Aboriginal children. Further consultation with Aboriginal communities is essential for understanding how to best sustain these oral health improvements for young Aboriginal children.

Oral health literacy and oral health outcomes in an adult population in Brazil.

BACKGROUND: To investigate the association between critical and communicative oral health literacy (OHL) and oral health outcomes (status, oral health-related quality of life and practices) in adults. METHODS: This cross-sectional study examined a household probability sample of 248 adults, representing 149,635 residents (20-64 years old) in Piracicaba-SP, Brazil. Clinical oral health and socioeconomic and demographic data, as well as data on oral health-related quality of life (OHIP-14) and health practices were collected. The oral examinations were carried out in the participants' homes, using the World Health Organization criteria for oral diseases. The critical and communicative OHL instrument was the primary independent variable, and it was measured using five Likert items that were dichotomized as 'high' ('agree' and 'strongly agree' responses for the 5 items) and 'low' OHL. Binary and multinomial logistic regressions were performed on each outcome (oral health status and practices), controlling for age, sex and socioeconomic status (SES). RESULTS: Approximately 71.5% presented low OHL. When adjusted for age and sex (first model) low OHL was associated with untreated caries (Odds Ratio = 1.92, 95% Confidence Interval = 1.07-3.45), tooth brushing <3 times a day (OR = 2.00, 1.11-3.62) and irregular tooth flossing (OR = 2.17, 1.24-3.80). After SES inclusion in the first model, significant associations were found for low OHL when the outcomes were: presence of biofilm (OR = 1.83, 1.08-3.33), dental care for emergency only (OR = 2.24, 1.24-4.04) and prevalence of oral health impact on quality of life (OR = 2.06, 1.15-3.69). CONCLUSION: Adjusting for age, sex and SES, OHL is related to a risk factor (biofilm) and a consequence of poor oral health (emergency dental visits) and can interfere with the impact of oral diseases on quality of life. As low OHL can be modified, the results support oral health promotion strategies directed at improving critical and communicative oral health literacy in adult populations.

Strategies for Meaningful Engagement between Community-Based Health Researchers and First Nations Participants.

The Baby Teeth Talk Study (BTT) is a partnership-based research project looking at interventions to prevent early childhood caries (ECC) in First Nations populations in Canada. Community-based researchers (CBRs) conducted preventive and behavioral interventions that targeted expectant mothers and their newborns, over a 3-year period. The work of the CBRs requires a great deal of training and skills to administer the interventions. It also requires a broad set of strategies to meaningfully engage participants to make health-promoting changes in their behavior to prevent ECC in their children. After implementing the intervention, BTT CBRs participated in interviews to explore the strategies they employed to engage participants in the prevention of ECC. CBRs perceived two key strategies as essential for meaningful engagement with BTT participants. First, CBRs indicated that their shared experiences through motherhood, First Nations identity, age, and childhood experience provided a positive foundation for dialog with participants that lead to build trust and rapport. Second, supportive interpersonal and culturally based communication skills of the CBR provided further foundation to engage with participants from a strength-based approach. For example, the CBRs knew how to effectively communicate in ways such as being gentle, non-intrusive, and avoiding any perception of judgment when discussing oral health behavior. In First Nations health research, CBRs can provide an essential link in engaging participants and the community for improvements in health. Researchers should carefully consider characteristics such as shared experience and ability to understand cultural communication styles when hiring CBRs in order to build a solid foundation of trust with research participants.

Comparing human resource planning models in dentistry: A case study using Canadian Armed Forces dental clinics.

OBJECTIVES: To compare two methods of allocating general dentists to Canadian Armed Forces (CAF) dental detachments: a dentist-to-population ratio model and a needs-based model. METHODS: Data obtained from CAF sources were analysed to compare models. Times assigned to treatment plan procedures were used as a proxy for treatment needs. Full-time equivalents (FTEs) were used as an indicator for the number of dentists allocated to each detachment. FTE values were adjusted for military dentists to account for time spent on compulsory nonclinical duties. The paired-samples t test was used to assess differences between the models for all clinics (dental detachments) and by clinic size. RESULTS: The dentist-to-population ratio model for the CAF population (n=68 183) estimated an allocation of 83.25 FTE general dentists to CAF dental detachments. Based on a systematic sample of the CAF population (n=2226), the needs-based model estimated the requirement for 64.71 FTE general dentists. The average difference between models was 0.71 FTE (SE=0.273), which was statistically significant (P=0.015). In terms of differences by clinic size, differences were more pronounced in clinics serving more than 4000 CAF personnel (2.63 FTEs, SE=0.613, P=0.008). CONCLUSIONS: The findings reveal differences between estimation models of <1 FTE, with higher estimates produced from the dentist-to-population ratio model. A larger difference was found in clinics with larger populations. The perceived overestimation of dental human resource requirements suggests that changing to a needs-based model may result in cost savings.

Tikanga Maori (Maori Customary Practices) in Oral Health Research.

Early childhood caries is a global health issue for Indigenous populations. The study, "Reducing disease burden and health inequalities arising from chronic dental disease among Indigenous children: an early childhood caries intervention," is being conducted in Australia, Canada, and Aotearoa/New Zealand. OBJECTIVE: To conduct the research in New Zealand using a kaupapa Maori (Maori philosophy) approach. METHODS: This is a mixed-method study incorporating quantitative and qualitative data whilst acknowledging Maori cultural practices by the utilization of Te Whare Tapa Wha, a model for Maori health and well-being. RESULTS: This paper describes the application of the four dimensions of this model, (spiritual, mental, physical and family dimensions) within the research activity. CONCLUSION: Health research projects that are undertaken with Indigenous populations must ensure that the research process embraces Indigenous cultural practices. In Aotearoa/New Zealand Maori leadership over the research process ensures meaningful and beneficial outcomes for the Maori Indigenous population.

Fidelity of Motivational Interviewing in an Early Childhood Caries Intervention Involving Indigenous Australian Mothers.

OBJECTIVES: This paper assessed the fidelity of an early childhood caries MI intervention among Aboriginal mothers in South Australia. METHODS: Four MI-trained staff delivered the intervention and all interviews were recorded. A randomly selected subset (n = 164, 41.2%) were tested for MI fidelity using the Motivational Interviewing Treatment Integrity (MITI) code 3.1.1. A further randomly selected 20 taped sessions were additionally scored by an external expert to assess external reliability. RESULTS: Mean scores for evocation, collaboration, autonomy/support, direction and empathy ranged from 3.5 (95% CI 3.4-3.7) to 4.1 (95% CI 4.0-4.2). The mean global score was 3.8 (95% 3.7-3.9). The Reflection:Question ratio was 0.9 (95% CI 0.8-1.0), % Open-ended Questions was 54.9 (95% CI 50.0-59.8), % Complex Reflections was 54.0 (95% CI 50.5-57.5) and % MI-adherent statements was 95.0 (95% CI 92.0-98.0). Inter-assessor reliability was high. CONCLUSIONS: Beginner to expert competency in fidelity to the MI model was observed.