Using Storytelling to Address Oral Health Knowledge in American Indian and Alaska Native Communities.

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.

The basic research factors questionnaire for studying early childhood caries.

BACKGROUND: We describe development of the Early Childhood Caries (ECC) Basic Research Factors Questionnaire (BRFQ), a battery of measures assessing common potential predictors, mediators, and moderators of ECC. Individual-, family-, and community-level factors that are linked to oral health outcomes across at-risk populations are included. Developing standard measures of factors implicated in ECC has the potential to enhance our ability to understand mechanisms underlying successful prevention and to develop more effective interventions. METHODS: The Early Childhood Caries Collaborating Centers (EC4), funded by National Institute of Dental and Craniofacial Research, developed the BRFQ, which was used across four randomized trials to develop and test interventions for reducing ECC in at-risk populations. Forty-five investigators from across the centers and NIDCR were involved in the development process. Eight "measures working groups" identified relevant constructs and effective measurement approaches, which were then categorized as "essential" or "optional" common data elements (CDEs) for the EC4 projects. RESULTS: Essential CDEs include 88 items, with an additional 177 measures categorized as optional CDEs. Essential CDEs fell under the following domains: oral health knowledge, oral health behavior, utilization/insurance and cost, parent/caregiver dental self-efficacy, quality of life, caregiver and family characteristics, and child characteristics. CONCLUSIONS: The BRFQ makes available a battery of measures that support efforts to understand population risk factors for ECC and to compare oral health outcomes across populations at risk. The BRFQ development process may be useful to other clinical research networks and consortia developing CDEs in other health research fields. TRIAL REGISTRATION: All the trial that used the BRFQ were registered at Clinicaltrial.gov NCT01116726 , April 29, 2010; NCT01116739 , May 3, 2010; NCT01129440 , May 21, 2010; and NCT01205971 , September 19, 2010.

An interpretive study of food, snack and beverage advertisements in rural and urban El Salvador.

BACKGROUND: Globalization and increased marketing of non-nutritious foods and beverages are driving a nutrition transition in developing countries, adversely affecting the health of vulnerable populations. This is a visual interpretive study of food, snack, and beverage advertisements (ads) in rural and urban El Salvador to discern the strategies and messages used to promote consumption of highly processed, commercialized products. METHODS: Digital photographs of billboard and wall advertisements recorded a convenience sample of 100 advertisements, including 53 from rural areas and 47 from urban areas in El Salvador. Advertisements were coded for location, type of product, visual details, placement and context. Qualitative methods were used to identify common themes used to appeal to consumers. RESULTS: Advertisements depicted "modern" fast foods, processed snacks and sugary beverages. Overall, the most prominent themes were: Cheap Price, Fast, Large Size, and Modern. Other themes used frequently in combination with these were Refreshment, Sports/Nationalism, Sex and Gender Roles, Fun/Happy Feelings, Family, Friendship and Community, and Health. In rural areas, beverage and snack food ads with the themes of cheap price, fast, and large size tended to predominate; in urban areas, ads for fast food restaurants and the theme of modernity tended to be more prominent. CONCLUSIONS: The advertisements represented a pervasive bombardment of the public with both explicit and subliminal messages to increase consumerism and shift dietary patterns to processed foods and beverages that are low in micronutrients and high in carbohydrates, sugar, fat and salt--dietary changes that are increasing rates of child and adult diseases including tooth decay, obesity, cardiovascular disease and cancer. Global food and beverage industries must be held accountable for the adverse public health effects of their products, especially in low-middle income countries where there are fewer resources to prevent and treat the health consequences. In addition, public health and governmental authorities should learn from the advertising strategies to promote social marketing of public health messages, and enact and enforce regulations to limit the advertisement and sale of unhealthy products, particularly for children in and around schools. This will create healthier social norms and environments for the entire population.

Using community participation to assess acceptability of "Contra Caries", a theory-based, promotora-led oral health education program for rural Latino parents: a mixed methods study.

BACKGROUND: Latino children experience more prevalent and severe tooth decay than non-Hispanic white and non-Hispanic black children. Few theory-based, evaluated and culturally appropriate interventions target parents of this vulnerable population. To fill this gap, the Contra Caries Oral Health Education Program, a theory-based, promotora-led education program for low-income, Spanish-speaking parents of children aged 1-5 years, was developed. This article describes qualitative findings of the acceptability of curriculum content and activities, presents the process of refinement of the curriculum through engaging the target population and promotoras, and presents results from the evaluation assessing the acceptability of the curriculum once implemented. METHODS: Focus groups were conducted with low-income Spanish-speaking parents of children 1-5 years living in a city in an agricultural area of California. Interviews were digitally recorded, translated and transcribed, checked for accuracy and the resulting data was thematically coded and analyzed using a social constructionist approach. The Contra Caries Oral Health Education Program was then implemented with a separate but similar sample, and after completing the program, participants were administered surveys asking about acceptability and favorite activities of the education program. Data were entered into a database, checked for accuracy, open-ended questions were categorized, and responses to close-ended questions counted. RESULTS: Twelve focus groups were conducted (N = 51), 105 parents attended the Contra Caries Oral Health Education Program, and 83 parents filled out surveys. Complete attendance and retention was high (89% and 90%, respectively). This study found that their children's oral health is a high priority. Parents were not only interested in, but actually attended classes focused on increasing their knowledge and skills with respect to early childhood oral health. The Contra Caries content and format was perceived as acceptable by parents. Strong opinions about curriculum content were expressed for including information on how caries starts and progresses, weaning from the bottle, oral health care for children and adults, motivational strategies for children's tooth brushing, dental visits and cavity restorations. CONCLUSIONS: The Contra Caries Oral Health Education Program was acceptable to low-income, Spanish-speaking parents of children 1-5 years. Participating in the curriculum development and revision process likely played an important role in the parents' high acceptability of the program.

Shades of Decay: The Meanings of Tooth Discoloration and Deterioration to Mexican Immigrant Caregivers of Young Children.

The objective of this article is to investigate parental understanding of tooth discoloration and decay and their related care seeking for young, Mexican-American children. The research design entailed semi-structured, face-to-face interviews conducted in Spanish with a convenience sample of 37 Mexican immigrant mothers of young children in a low-income urban neighborhood. Five major color terms - white, off-white, yellow, brown, and black - were used to describe tooth discoloration, the causes of which were mainly unrecognized or attributed to poor oral hygiene and exposure to sweet substances. Mothers also described three major levels of deterioration of the structural integrity of teeth due to caries, from stains to decayed portions to entirely rotten. A trend was observed between use of darker discoloration terms and extensive carious lesions. Teeth described as both dark in color and structurally damaged resulted in seeking of professional care. The paper concludes with the finding that Spanish terms used to describe tooth discoloration and carious lesions are broad and complex. Mexican immigrant mothers' interpretations of tooth discoloration and decay may differ from dental professionals' and result in late care seeking. Increased understanding between dental practitioners and caregivers is needed to create educational messages about the early signs of tooth decay.

Spanish-speaking Mexican-American parents' experiences while navigating the dental care system for their children.

OBJECTIVES: The purpose of this study is to describe Mexican-American parents' experiences navigating the dental care system for their children. METHODS: Thirty in-depth qualitative interviews were conducted with Spanish-speaking caregivers of young children in an urban county of Northern California, asking about their experiences navigating dental care for their children. Interviews were digitally recorded, translated, transcribed, coded, and analyzed using standard qualitative procedures. RESULTS: Caregivers reported challenges that highlight how various aspects of navigating the health care system are elemental to oral health literacy. These included making appointments, finding a provider they trust, using their dental insurance, and communicating with the dental care provider. CONCLUSIONS: When addressing oral health literacy, it is important to consider the navigational components to improve children's oral health literacy.

Maternal beliefs and motivations for first dental visit by low-income Mexican American children in California.

PURPOSE: The purpose of this study was to examine Mexican American immigrant caregivers' beliefs and motivations surrounding the first dental visit for their young children (median age=5-years-old). METHODS: Qualitative interviews were conducted among a convenience sample of 48 low-income, Mexican American mothers about their young children's oral health. Transcripts were independently read, coded, and thematically analyzed. RESULTS: Half (51%) of first dental visits were for parent-initiated reasons, including: for pain or visible dental problems; for parent's proactive desire to get a checkup; or to avoid future dental problems. The other half was initiated by external prompts, especially pediatrician recommendations and school requirements. Once a child went to the dentist for his/her first visit, 94% continued with regular checkups. The mean age for a first dental visit was 3-years-old. Three parents reported cases in which dentists discouraged visits for symptomatic children before they were 3-years-old. CONCLUSIONS: The low-income, urban Mexican American parents interviewed take their children to their first dental visit when they are approximately 3-years-old, much later than the recommended 1-year-old first visit for this at-risk population. Physicians are well positioned to play an important role in prompting first dental visits.

Water consumption beliefs and practices in a rural Latino community: implications for fluoridation.

OBJECTIVE: Adequate fluoride exposure is especially important for those experiencing disproportionately high prevalence of dental caries, such as rural Latino farm-workers and their children. Water is an important source of fluoride. This qualitative study examined water consumption beliefs and practices among Latino parents of young children in a rural community. METHODS: Focus groups and open-ended in-depth interviews explored parents beliefs about tap water, beverage preferences, and knowledge of fluoride. A questionnaire documented socio-demographic characteristics and water consumption practices. Qualitative analysis revealed how water-related beliefs, social and cultural context, and local environment shaped participants' water consumption. RESULTS: The vast majority of participants (n = 46) avoided drinking unfiltered tap water based on perceptions that it had poor taste, smell, and color, bolstered by a historically justified and collectively transmitted belief that the public water supply is unsafe. Water quality reports are not accessible to many community residents, all of whom use commercially bottled or filtered water for domestic consumption. Most participants had little knowledge of fluoride beyond a general sense it was beneficial. While most participants expressed willingness to drink fluoridated water, many emphatically stated that they would do so only if it tasted, looked, and smelled better and was demonstrated to be safe. CONCLUSIONS: Perceptions about water quality and safety have important implications for adequate fluoride exposure. For vulnerable populations, technical reports of water safety have not only to be believed and trusted but matched or superseded by experience before meaningful change will occur in people's water consumption habits.

Stigmatized biologies: Examining the cumulative effects of oral health disparities for Mexican American farmworker children.

Severe early childhood caries (ECC) can leave lasting effects on children's physical development, including malformed oral arches and crooked permanent dentition. This article examines the way that the ECC of Mexican American farmworker children in the United States sets them up for lasting dental problems and social stigma as young adults. We examine the role of dietary and environmental factors in contributing to what we call "stigmatized biologies," and that of market-based dental public health insurance systems in cementing their enduring effects. We adapt Margaret Lock's term, local biology, to illustrate the way that biology differs not only because of culture, diet, and environment but also because of disparities in insurance coverage. By showing the long-term effects of ECC and disparate dental treatment on farmworker adults, we show how the interaction of immigrant caregiving practices and underinsurance can having lasting social effects. An examination of the long-term effects of farmworker children's ECC illustrates the ways that market-based health care systems can create embodied differences that in turn reproduce a system of social inequality.

Rural Latino farmworker fathers' understanding of children's oral health.

PURPOSE: This study's purpose was to examine rural Latino fathers' understanding of their children's oral health. METHODS: A convenience sample (n=20) of fathers from a small agricultural community in California was recruited door-to-door and interviewed in their homes. Individual qualitative interviews in Spanish were conducted. Interviews were audiotaped, translated, and transcribed. Codes were developed, and the text was analyzed for recurrent themes. RESULTS: Fathers came from Mexico (n=15) and El Salvador (n=5). Fathers had very little understanding of the etiology and clinical signs of dental caries. Overall, 18 of 19 fathers reported that their wife was primarily responsible for taking care of the children's hygiene. Fathers agreed that children's teeth should be taken care of from a young age, considered to be after 2 years. The fathers described very minimal hygiene assistance given to children by either parent and often considered a verbal reminder to be sufficient assistance. Fathers generally thought a child did not need supervision after approximately age 4 (range=1-11 years). CONCLUSIONS: While rural Latino fathers might not actively participate in their children's oral hygiene, they do place value on it. Men are supportive of dental treatments, albeit later than recommended. Educational messages aimed at these families will disseminate to the fathers, indirectly.

Mexican American mothers' initiation and understanding of home oral hygiene for young children.

PURPOSE: To investigate caregiver beliefs and behaviors as key issues in the initiation of home oral hygiene routines. Oral hygiene helps reduce the prevalence of early childhood caries, which is disproportionately high among Mexican-American children. METHODS: Interviews were conducted with a convenience sample of 48 Mexican-American mothers of young children in a low income, urban neighborhood. Interviews were digitally recorded, translated, transcribed, coded and analyzed using standard qualitative procedures. RESULTS: The average age of tooth brushing initiation was 1.8 +/- 0.8 years; only a small proportion of parents (13%) initiated oral hygiene in accord with American Dental Association (ADA) recommendations. Mothers initiated 2 forms of oral hygiene: infant oral hygiene and regular tooth brushing. For the 48% of children who participated in infant oral hygiene, mothers were prompted by pediatrician and social service (WIC) professionals. For regular tooth brushing initiation, a set of maternal beliefs exist about when this oral hygiene practice becomes necessary for children. Beliefs are mainly based on a child's dental maturity, interest, capacity and age/size. CONCLUSIONS: Most (87%) of the urban Mexican-American mothers in the study do not initiate oral hygiene practices in compliance with ADA recommendations. These findings have implications for educational messages.

A storytelling intervention reduces childhood caries risk behaviors among American Indian and Alaska Native mothers in Northern California.

OBJECTIVES: To evaluate a storytelling intervention targeting the oral health beliefs, knowledge, and behaviors of AIAN pregnant women and mothers. METHODS: Fifty-three adult AIAN women from three tribal communities in Northern California participated. The intervention story delivered oral health messaging using a traditional storytelling format. The effect of the intervention on self-reported oral health behaviors, dental knowledge, and beliefs was assessed using a pretest-posttest design, with an additional six-month follow-up. Tests of repeated measures using Generalized Linear Models were conducted to assess changes in oral health knowledge, beliefs, and behaviors. RESULTS: Knowledge and beliefs significantly increased as a result of the intervention and persisted after six months. A consistent, significant increase in positive oral health behaviors from baseline to six-months was also observed. CONCLUSIONS: The results of this intervention study suggest promise for traditional storytelling to increase oral health-related knowledge, beliefs, and behaviors among self-identified AIAN pregnant women and mothers.

Rural Latino immigrant caregivers' conceptions of their children's oral disease.

OBJECTIVE: The aim of this study was to examine Latino immigrant caregivers' explanatory models of the causes of early childhood caries (ECC). METHODS: In a rural area, we conducted 71 open-ended qualitative interviews with 26 Mexican immigrant and 12 Salvadoran immigrant caregivers of children under 6 about the causes of ECC. Two researchers independently read each interview and classified each interviewee's response. RESULTS: Caregivers mentioned three biomedical causes of oral disease (sweets, poor oral hygiene, and bottle-feeding) and two lay or popular causes (lack of milk consumption and "bad" genes). Although caregivers were aware that the consumption of sweet foods causes decay they expressed particular confusion about how bottle-feeding causes decay. Nineteen caregivers attributed decay specifically to bottle-feeding, yet 14 believed the cause of decay was the bottle's nipple. Seven Mexican immigrant caregivers attributed their children's decay specifically to a lack of calcium, and six immigrant caregivers to "bad teeth genes." CONCLUSIONS: Conceptions of oral disease derived from the caregivers' own dental experiences, their conceptions of the body, and interactions with dental professionals. The fact that biomedical explanations dominate the list of causes of caries for both groups indicates that the caregivers' explanatory models of oral disease are powerfully shaped by interactions with health professionals. Immigrant caregivers' mistaking of the baby bottle's nipple as the source of decay indicates the need for more effective oral health promotion. Yet the Mexican immigrants' conceptions of a lack of calcium as a major factor in their children's decay may illustrate a strong cultural link between teeth and milk.

An ethnographic study of Latino preschool children's oral health in rural California: Intersections among family, community, provider and regulatory sectors.

BACKGROUND: Latino children experience a higher prevalence of caries than do children in any other racial/ethnic group in the US. This paper examines the intersections among four societal sectors or contexts of care which contribute to oral health disparities for low-income, preschool Latino1 children in rural California. METHODS: Findings are reported from an ethnographic investigation, conducted in 2005-2006, of family, community, professional/dental and policy/regulatory sectors or contexts of care that play central roles in creating or sustaining low income, rural children's poor oral health status. The study community of around 9,000 people, predominantly of Mexican-American origin, was located in California's agricultural Central Valley. Observations in homes, community facilities, and dental offices within the region were supplemented by in-depth interviews with 30 key informants (such as dental professionals, health educators, child welfare agents, clinic administrators and regulatory agents) and 47 primary caregivers (mothers) of children at least one of whom was under 6 years of age. RESULTS: Caregivers did not always recognize visible signs of caries among their children, nor respond quickly unless children also complained of pain. Fluctuating seasonal eligibility for public health insurance intersected with limited community infrastructure and civic amenities, including lack of public transportation, to create difficulties in access to care. The non-fluoridated municipal water supply is not widely consumed because of fears about pesticide pollution. If the dentist brought children into the clinic for multiple visits, this caused the accompanying parent hardship and occasionally resulted in the loss of his or her job. Few general dentists had received specific training in how to handle young patients. Children's dental fear and poor provider-parent communication were exacerbated by a scarcity of dentists willing to serve rural low-income populations. Stringent state fiscal reimbursement policies further complicated the situation. CONCLUSION: Several societal sectors or contexts of care significantly intersected to produce or sustain poor oral health care for children. Parental beliefs and practices, leading for example to delay in seeking care, were compounded by lack of key community or economic resources, and the organization and delivery of professional dental services. In the context of state-mandated policies and procedures, these all worked to militate against children receiving timely care that would considerably reduce oral health disparities among this highly disadvantaged population.

Oral health-related cultural beliefs for four racial/ethnic groups: Assessment of the literature.

BACKGROUND: The purpose of this study was to assess information available in the dental literature on oral health-related cultural beliefs. In the US, as elsewhere, many racial/ethnic minority groups shoulder a disproportionate burden of oral disease. Cultural beliefs, values and practices are often implicated as causes of oral health disparities, yet little is known about the breadth or adequacy of literature about cultural issues that could support these assertions. Hence, this rigorous assessment was conducted of work published in English on cultural beliefs and values in relation to oral health status and dental practice. Four racial/ethnic groups in the US (African-American, Chinese, Filipino and Hispanic/Latino) were chosen as exemplar populations. METHODS: The dental literature published in English for the period 1980-2006 noted in the electronic database PUBMED was searched, using keywords and MeSH headings in different combinations for each racial/ethnic group to identify eligible articles. To be eligible the title and abstract when available had to describe the oral health-related cultural knowledge or orientation of the populations studied. RESULTS: Overall, the majority of the literature on racial/ethnic groups was epidemiologic in nature, mainly demonstrating disparities in oral health rather than the oral beliefs or practices of these groups. A total of 60 relevant articles were found: 16 for African-American, 30 for Chinese, 2 for Filipino and 12 for Hispanic/Latino populations. Data on beliefs and practices from these studies has been abstracted, compiled and assessed. Few research-based studies were located. Articles lacked adequate identification of groups studied, used limited methods and had poor conceptual base. CONCLUSION: The scant information available from the published dental and medical literature provides at best a rudimentary framework of oral health related ideas and beliefs for specific populations.

Importance of Content and Format of Oral Health Instruction to Low-income Mexican Immigrant Parents: A Qualitative Study.

PURPOSE: This study's purpose was to explore how content and format of children's oral health instruction in the dental clinic is perceived by parents and might affect parents' knowledge and behaviors. METHODS: Thirty low-income Mexican immigrant parents of children age five years and under were recruited from dental clinics in 2015 to 2016. In-person qualitative interviews in Spanish about their children's and their own experiences of dental care and home oral hygiene practices were conducted, digitally recorded, translated, and transcribed. Data analysis involved iteratively reading text data and developing and refining codes to find common themes. RESULTS: Twenty-five of 30 parents recalled receiving oral hygiene instruction, and 18 recalled receiving nutrition instruction and were included in analyses. The format and effectiveness of instruction varied. More engaging educational approaches were recalled and described in more detail than less engaging educational approaches. As a result of oral hygiene and nutritional instruction, most parents reported changing their oral hygiene home behaviors for their children; half aimed to reduce purchasing sugary foods and drinks. CONCLUSIONS: Most parents recalled receiving oral hygiene and nutrition instruction as part of their child's dental visit and reported incorporating the instruction and recommendations they received into their children's home routine.

Survey of Knowledge, Beliefs, and Behaviors of Migrant Vietnamese Parents Regarding Young Children's Oral Health.

Purpose: The purpose of this study was to investigate the oral health knowledge, beliefs, and behaviors of migrant Vietnamese parents of 1-5 year-olds in San Jose, California.Method: A verbally-administered survey was conducted with a convenience sample of 45 Vietnamese parents recruited at San Jose public libraries. Following preliminary screening, written informed consent was obtained from eligible individuals. A pre-tested, structured 94-item questionnaire was used to collect information regarding parent demographics, and the parent's knowledge, beliefs, and behaviors about children's oral health. Simple descriptive statistics were used to analyze the data.Results: Vietnamese parents acknowledged a number of basic concepts regarding early childhood caries (ECC), such as influences of sugar consumption, oral hygiene, and bottle use. Unlike other groups, they reported some familiarity with the role of bacteria in caries etiology. Oral health knowledge and beliefs, however, were not reflected in parental oral health behaviors such as supervision of children's brushing. Knowledge about the preventive role of fluoride was limited and varied among the population. Parental knowledge and behaviors did not vary by education level or length of residence in US.Conclusion: Vietnamese parents demonstrated reasonably good oral health knowledge, but poor behavioral guidance of their children's oral health, indicating the need for continued parental education emphasizing age-appropriate oral care and the preventative role of fluoride.

Oral health beliefs, knowledge, and behaviors in Northern California American Indian and Alaska Native mothers regarding early childhood caries.

OBJECTIVES: To assess the oral health beliefs, knowledge, and behaviors related to early childhood caries (ECC) risk in a convenience sample of American Indian and Alaska Native (AIAN) mothers residing in rural Northern California communities. METHODS: Fifty-three mothers of young children were recruited from three tribal communities in Northern California with the assistance of the California Rural Indian Health Board, Inc. and its California Tribal Epidemiology Center and Dental Support Center. Trained study staff administered questionnaires to obtain basic socio-demographic information, to survey participants on their oral health beliefs, knowledge, and behaviors as related to ECC risk, and to identify possible barriers to their accessing professional oral health care. Analyses of covariance were used to explore associations between socio-demographic indicators and oral health behaviors, after controlling for knowledge, beliefs and barriers to care. RESULTS: Overall, 53 percent of participants reported their oral health as "fair" or "poor." Mothers' education (high) and being employed were positively associated with better oral health behavior scores. Additionally, 72 percent of mothers reported having one or more barriers to oral health care including access. There was a significant relation (P = 0.03) between high number of reported barriers to oral health care and low oral health behavior scores. CONCLUSIONS: Despite generally high-level oral health knowledge, perceptions of self and child oral health remains low in this sample of AIAN mothers. Factors identified as being associated with oral health behaviors in this sample were similar to those found in other health disparities populations.

Retention strategies for health disparities preventive trials: findings from the Early Childhood Caries Collaborating Centers.

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.

Acceptability of Salt Fluoridation in a Rural Latino Community in the United States: An Ethnographic Study.

Compared to other population groups in the United States, caries (tooth decay) is a disproportionately prevalent disease among Latino populations, especially among low-income and rural sub-groups and children under five years of age. Fluoride is a primary preventive for caries. While water fluoridation is a major and effective public health means for delivering fluoride on a mass scale, it does not reach many rural areas or population groups such as Latinos who eschew drinking water from municipal sources. This study examines the acceptability to such groups of salt fluoridation, an alternate means of delivering fluoride long used on a global scale. An ethnographic study in California's rural Central Valley was performed. Thirty individual interviews and 5 focus groups (N = 61) were conducted in Spanish to investigate low-income Latino migrant caregivers' experiences, views and understandings of domestic salt, oral health, caries prevention and fluoride. Audio data were transcribed, translated, coded and thematically analyzed. Table salt was readily available and frequently consumed. Both adult and child daily sodium consumption was high. Despite a general feeling that it was good, and present in dentifrices or dietary supplements, most participants had little knowledge about fluoride. Concerns were raised about cardio-vascular and other possibly deleterious effects if an increase in salt consumption occurred because fluoridated salt was viewed as having 'extra' benefits. Once informed about fluoride's safety and role in caries prevention, most participants expressed willingness to use fluoridated salt, especially if it benefitted children. Reassurance about its safety and benefits, and demonstration of its taste, were important aspects of acceptance. Taste was paramount. Participants would not consume more fluoridated salt than their current salt as that would result in unpleasant changes in food flavor and taste. While salt fluoridation is acceptable, the feasibility of producing and distributing fluoridated salt in the United States is, however, complex and challenging.