What really happens in the home: a comparison of parent-reported and observed tooth brushing behaviors for young children.

BACKGROUND: Most studies of tooth brushing behaviors rely on self-report or demonstrations of behaviors conducted in clinical settings. This study aimed to determine the feasibility of objective assessment of tooth brushing behaviors in the homes of high-risk children under three years old. We compared parent self-report to observations to determine the accuracy of self-report in this population. METHODS: Forty-five families were recruited from dental and medical clinics and a community social service agency. Research staff asked questions about oral health behaviors and observed tooth brushing in the homes. Brushing was also video-recorded. Video-recordings were coded for brushing behaviors by staff that did not collect the primary data; these abstracted data were compared to those directly observed in homes. RESULTS: Most families were Hispanic (76%) or Black (16%) race/ethnicity. The majority of parents had a high school education (42%) or less (24%). The mean age of children was 21 months. About half of parents reported brushing their child's teeth twice a day (58%). All parents tried to have their children brush, but three children refused. For brushing duration, 70% of parents reported differently than was observed. The average duration of brushing was 62.4 s. Parent report of fluoride in toothpaste frequently did not match observations; 39% said they used toothpaste with fluoride while 71% actually did. Sixty-eight percent of parents reported using a smear of toothpaste, while 61% actually did. Brushing occurred in a variety of locations and routines varied. Abstracted data from videos were high in agreement for some behaviors (rinse with water, floss used, brushing location, and parent involvement: Kappa 0.74-1.0). Behaviors related to type of brushing equipment (brushes and toothpaste), equipment storage, and bathroom organization and clutter had poor to no agreement. CONCLUSIONS: Observation and video-recording of brushing routines and equipment are feasible and acceptable to families. Observed behaviors are more accurate than self-report for most components of brushing and serve to highlight some of the knowledge issues facing parents, such as the role of fluoride.

Building a Pediatric Oral Health Training Curriculum for Community Health Workers.

OBJECTIVES: Community health workers (CHWs) are a promising approach to oral health promotion in high-risk populations. This article describes the process of creating a pediatric oral health CHW training curriculum. DESIGN: Existing curricula were identified through outreach efforts to experts in the oral health and CHW fields, as well as PubMed and Google searches. After coding basic information, curricula were mapped to define oral health domains. Then group discussion was employed to determine final curriculum contents. SETTING: United States. INCLUSION CRITERIA: Curricula were included if they addressed oral health, were in English or Spanish, involved US populations, did not target dental clinicians, and whether sufficient data could be obtained. MAIN OUTCOME MEASURES: Curricula were evaluated for delivery format, number of hours, target audience, inclusion of CHWs, completeness, and oral health content. RESULTS: Eighteen unique curricula were identified; 14 (78%) were CHW specific. Pathologic factors, caries formation, toothbrushing basics, flossing, nutrition, sugar-sweetened beverages, oral health recommendations, baby bottle tooth decay, fluoride treatments, and fluoride were covered to some extent in 75% of curricula. More than half did not mention types of teeth, oral health during pregnancy, antifluoride, cultural humility, and special needs populations. After comparing CHW curricula with non-CHW curricula, the original 26 oral health domains were condensed into 10 CHW training domains. CONCLUSION: Using existing evidence and expert insight, an oral health CHW training curriculum outline was created that emphasizes behaviors, social support, and navigation assistance to promote preventive oral health behaviors in families of young children. This has implications beyond oral health. CHW programs are expanding to address the social determinants of health. The process of creating this curriculum and its basic elements can be applied to other disease areas. Clearly defined trainings that are made publicly available, such as this one, support efforts to standardize the CHW field in preparation for CHW certification and reimbursement in the future.

Community health worker intervention to improve tooth brushing in young children: Results from a cluster randomized controlled trial.

OBJECTIVES: Coordinated Oral health Promotion (CO-OP) Chicago is a cluster randomized controlled trial testing the efficacy of a community health worker (CHW) intervention to improve tooth brushing in low-income children. METHODS: Four hundred twenty children under 3 years old (mean 21.5 months) were recruited from 20 sites in or near Chicago, IL. Children were identified mainly as Black race (41.9%) or Hispanic ethnicity (53.8%) and most (85.2%) had Medicaid. Intervention families were offered four CHW home visits over 1 year. Brushing frequency was self-reported. Plaque score was determined from images collected in homes using disclosing solution. Analyses used GEE logistic models with variable selection at p < .05. RESULTS: At enrolment, 45.0% of families reported twice a day or more child brushing frequency, and child plaque scores were poor (mean of 1.9, SD: 0.6). Data were obtained from 87.1% of children at 6 months and 86.2% at 12 months. In the CHW intervention arm (10 sites, N = 211), 23.7% received 4 visits, 12.8% 3 visits, 21.3% 2 visits, 23.2% 1 visit and 19% no visits from CHWs. No intervention effect was seen for brushing frequency or plaque score. Child brushing frequency improvement over time was associated with a range of child and caregiver factors. The only factor associated with a change in plaque score over time was parent involvement in brushing. CONCLUSIONS: Oral-health-specific CHW services were not associated with improved brushing behaviours in these young children. However, caregiver involvement with brushing supported more quality brushing. More robust interventions are needed to support families during this critical developmental period.

Oral Health Behaviors for Young Low-Income Urban Children during the COVID-19 Pandemic: A Mixed Methods Analysis.

This research assessed oral health behaviors changes in urban families with young children during the stay-at-home period of the COVID-19 pandemic (Nov 2020-August 2021). Survey data on oral health behaviors were collected in homes at three points before COVID-19, and via phone during COVID-19. A subset of parents and key informants from clinics and social service agencies completed in-depth interviews via video/phone. Of the 387 parents invited, 254 completed surveys in English or Spanish (65.6%) during COVID-19. Fifteen key informant interviews (25 participants) and 21 family interviews were conducted. The mean child age was 4.3 years. Children identified as mainly Hispanic (57%) and Black race (38%). Parents reported increased child tooth brushing frequency during the pandemic. Family interviews highlighted changes in family routines that impacted oral health behaviors and eating patterns, suggesting less optimal brushing and nutrition. This was linked to changed home routines and social presentability. Key informants described major disruptions in oral health services, family fear, and stress. In conclusion, the stay-at-home period of the COVID-19 pandemic was a time of extreme routine change and stress for families. Oral health interventions that target family routines and social presentability are important for families during times of extreme crisis.

Oral health behaviors for young low-income urban children during the COVID-19 pandemic: a mixed methods analysis.

This research assessed oral health behaviors changes in urban families with young children during the stay-at-home period of the COVID-19 pandemic. Survey data on oral health behaviors were collected in homes at three points over one year before COVID-19, and then via phone during COVID-19. Multivariate logistic regression was used to model tooth brushing frequency. A subset of parents completed in-depth interviews via video/phone that expanded on oral health and COVID-19. Key informant interviews via video/phone were also conducted with leadership from 20 clinics and social service agencies. Interview data were transcribed and coded, and themes were extracted. COVID-19 data collection went from Nov 2020 - August 2021. Of the 387 parents invited, 254 completed surveys in English or Spanish (65.6%) during COVID-19. Fifteen key informant (25 participants) and 21 parent interviews were conducted. The mean child age was approximately 4.3 years. Children identified as mainly Hispanic (57%) and Black race (38%). Parents reported increased child tooth brushing frequency during the pandemic. Parent interviews highlighted significant changes in family routines that impacted oral health behaviors and eating patterns, suggesting less optimal brushing and nutrition. This was linked to changed home routines and social presentability. Key informants described major disruptions in their oral health services and significant family fear and stress. In conclusion, the stay-at-home period of the COVID-19 pandemic was a time of extreme routine change and stress for families. Oral health interventions that target family routines and social presentability are important for families during times of extreme crisis.

What Chicago community organizations needed to implement COVID-19 interventions: lessons learned in 2021.

Introduction: As the COVID-19 pandemic placed a spotlight on the health inequities in the United States, this study aimed to determine the local programmatic needs of community organizations (CO) delivering COVID-19 interventions across Chicago. Methods: In the summer of 2021, the Chicagoland CEAL Program interviewed 34 COs that were providing education, testing, and/or vaccinations in communities experiencing poor COVID-19 outcomes. The interviews were analyzed thematically and organized around logistical challenges and funding/resource needs. Results: The COs routinely offered testing (50%) or vaccinations (74%), with most (56%) employing some programmatic evaluation. Programs utilizing trusted-messenger systems were deemed most effective, but resource-intensive. CO specific needs clustered around sustaining effective outreach strategies, better CO coordination, wanting comprehensive trainings, improving program evaluation, and promoting services and programs. Conclusion: The COs reached populations with low-vaccine confidence using trusted messengers to overcome mistrust. However, replenishment of the resources needed to sustain such strategies should be prioritized. Leveraging the Chicagoland CEAL Program to help negotiate community organizations' interorganizational coordination, create training programs, and provide evaluation expertise are deliverable supports that may bolster COVID-19 prevention. Policy implications: Achieving health justice requires that all institutions of power participate in meaningful community engagement, help build community capacity, and infuse health equity throughout all aspects of the research and program evaluation processes.

Oral community health worker-led interventions in households with average levels of psychosocial factors.

Introduction: Household-level psychosocial stress levels have been linked to child tooth brushing behaviors. Community health worker (CHW) interventions that target psychosocial factors in high-risk communities have been associated with changes in health behaviors. Aim: Observe changes in psychosocial factors over time and an association between psychosocial factors and CHW intervention dose amongst urban Chicago families. Patients and methods: Participants (N = 420 families) were recruited from 10 community clinics and 10 Women, Infants, or Children (WIC) centers in Cook County, Illinois to participate in a clinical trial. Research staff collected participant-reported psychosocial factors (family functioning and caregiver reports of depression, anxiety, support, and social functioning) and characteristics of CHW-led oral health intervention visits (number, content, child engagement) at 0, 6, and 12 months. CHWs recorded field observations after home visits on household environment, social circumstances, stressors, and supports. Results: Participants across the cohort reported levels of psychosocial factors consistent with average levels for the general population for nearly all measures. Psychosocial factors did not vary over time. Social functioning was the only measure reported at low levels [32.0 (6.9); 32.1 (6.7); 32.7 (6.9); mean = 50 (standard deviation)] at 0, 6, and 12 months. We did not observe a meaningful difference in social functioning scores over time by exposure to CHW-led intervention visits (control arm, 0, 1, 2, 3, and 4 visits). Field observations made by CHWs described a range of psychosocial stress related to poverty, language barriers, and immigration status. Conclusion: The unexpectedly average and unchanging psychosocial factors over time, in the context of field observations of stress related to poverty, lack of support, immigration status, and language barriers, suggests that our study did not adequately capture the social determinants of health related to oral health behaviors or that measurement biases precluded accurate assessment. Future studies will assess psychosocial factors using a variety of instruments in an attempt to better measure psychosocial factors including social support, depression, anxiety, functioning, trauma and resilience within our urban population. We will also look at neighborhood-level factors of community distress and resilience to better apply the social ecologic model to child oral health behaviors.

COVID-19 Impact on Community-Based Participatory Randomized Controlled Trials-Lessons From the Oral Health Disparities in Children Consortium.

The COVID-19 pandemic has had a major impact on nearly every sector of science and industry worldwide, including a significant disruption to clinical trials and dentistry. From the beginning of the pandemic, dental care was considered high risk for viral transmission due to frequent aerosol-generating procedures. This resulted in special challenges for dental providers, oral health care workers, patients, and oral health researchers. By describing the effect that the COVID-19 pandemic had on four community-based randomized clinical trials in the Oral Health Disparities in Children (OHDC) Consortium, we highlight major challenges so researchers can anticipate impacts from any future disruptions.

Tooth Brushing Behaviors and Fluoridated Toothpaste Use Among Children Younger Than Three Years Old in Chicago.

Purpose: To describe toothbrushing frequency/duration and toothpaste use among young children in an urban, vulnerable population in Chicago, Ill., USA.
Methods: Caregivers of children younger than three years old were recruited from university and community pediatric dental clinics. Caregivers completed a 37-item questionnaire in English or Spanish about predictors/covariates (demographics, child/caregiver oral health, access to dental care) and primary outcomes (child toothbrushng behaviors, toothpaste use). Models employed generalized logit and ordinal logistic regression.
Results: A total of 148 caregivers completed the survey. The average child age was 18.8 months (±7.4 SD). Approximately 41 percent of children brushed once a day or less, and 19 percent of caregivers did not regularly assist. Almost all children used toothpaste (96 percent), but 36 percent of caregivers did not know if it contained fluoride. Increased child brushing frequency was associated with older child age, higher caregiver brushing frequency, history of a child dental visit, and caregiver assistance (P<0.05). Children with a history of dental visits were seven times more likely to brush for 30 seconds or more, and receiving caregiver assistance was associated with brushing longer than two minutes (P <0.05).
Conclusion: Most children brushed at least once daily and nearly all of them used toothpaste. Access to dental care, parental involvement, and parental oral health were associated with favorable child toothbrushing behaviors. Toothbrushing duration, frequency, and encouraging family assistance are modifiable protective factors and opportunities for intervention.

Design and sample characteristics of COordinated Oral health Promotion (CO-OP) Chicago: A cluster-randomized controlled trial.

COordinated Oral health Promotion (CO-OP) Chicago is a two-arm cluster-randomized trial with a wait-list control. The primary aim is to evaluate the efficacy of an oral health community health worker (CHW) intervention to improve oral health behaviors in low-income, urban children under the age of three years. Exploratory aims will determine cost-effectiveness, and if any CHW intervention impact on child tooth brushing behaviors varies when CHWs are based out of a medical clinic compared to a community setting. This paper describes progress toward achieving these aims. Participating families were recruited from community social service centers and pediatric primary care medical clinics in Cook County, Illinois. Sites were cluster-randomized to CHW intervention or usual services (a wait-list control). The intervention is oral health support from CHWs delivered in four visits to individual families over one year. The trial sample consists of 420 child/caregiver dyads enrolled at the 20 participating sites over 11 months. Participant demographics varied across the sites, but primary outcomes values at baseline did not. Data on brushing frequency, plaque, and other oral health behaviors are collected at three timepoints: baseline, 6-, and 12-months. The primary analysis will assess differences in caregiver-reported child brushing frequency and observed plaque score between the two arms at 12-months. The trial is currently in the active intervention phase. The trial's cluster-randomized controlled design takes a real-world approach by integrating into existing health and social service agencies and collecting data in participant homes. Results will address an important child health disparity. ClinicalTrials.gov identifier: NCT03397589. CLINICAL TRIAL REGISTRATION: University of Illinois at Chicago Protocol Record 2017-1090. National Institutes of Dental & Craniofacial Research of the National Institutes of Health (NIDCR) Protocol Number: 17-074-E. NCT03397589.

Formative research implications on design of a randomized controlled trial for oral health promotion in children.

BACKGROUND: The COordinated Oral health Promotion (CO-OP) Chicago trial will test the efficacy of a community health worker (CHW) intervention to improve oral health behaviors for children at high risk for early childhood caries. Before implementing the cluster-randomized controlled trial, we conducted a formative assessment to determine the final design. We used qualitative methods to assess the feasibility and acceptability of the proposed recruitment, data collection, and intervention plan. METHODS: Key informant interviews (N = 37) and site observations were conducted at 10 pediatric primary care clinics and 10 Special Supplemental Nutrition Program for Women Infant and Children (WIC) centers to gain insight from providers and administrators at the locations where recruitment and intervention will occur. Eight focus groups (N = 68) were conducted with caregivers of children to capture the parent perspective. Conceptual coding methods from grounded theory were applied to organize the data into the final themes. RESULTS: Families, clinics, and WIC centers were all very interested in additional supports for oral health and were enthusiastic about CHWs. Challenges included competing family priorities that might interfere in study enrollment and intervention efficacy. Physical space for enrollment and intervention delivery was a major barrier for some sites. Home visits for data collection and intervention delivery would be unacceptable for some families. These challenges and barriers prompted us to make major changes in our trial design. We opened the option for data collection to occur in multiple locations. We eliminated the home-only arm of the trial. Clinics and WIC centers that are randomized to the non-intervention arm will now have CHWs available at the study conclusion. Finally, we aligned the CHW oral health topics to the needs of families. CONCLUSIONS: We conducted this comprehensive formative assessment to determine the feasibility and acceptability of the CO-OP Chicago trial. While overall acceptance of the trial was high, the results highlighted specific issues with the proposed trial implementation plan and led to several critical design changes. This type of formative work requires a significant upfront investment but we expect it will translate into savings through better recruitment, retention, intervention implementation and adherence, and result dissemination.

Increasing Prevalence of US Elementary School Gardens, but Disparities Reduce Opportunities for Disadvantaged Students.

BACKGROUND: We examined the prevalence of school garden programs at US public elementary schools. The study examined time trends, demographic and regional disparities, and associations with related programs such as farm-to-school. METHODS: Annual surveys were gathered from nationally representative samples of elementary schools between 2006-2007 and 2013-2014. Annual samples ranged from 553 to 748 schools. RESULTS: The prevalence of gardens increased steadily from 11.9% in 2006-2007 to 31.2% in 2013-2014 (p < .001). In multivariate logistic regressions the prevalence of garden programs varied significantly by school characteristics. Gardens were more prevalent in the west than in other regions. Gardens were less prevalent at schools serving higher proportions of lower-income students, and were more prevalent at urban schools than in suburbs, towns, or rural areas. Gardens were more common at schools with farm-to-school programs. Gardens also were associated with offering formal classroom-based nutrition education. CONCLUSIONS: Garden programs in elementary schools have increased over time, but there is room for wider implementation, particularly at schools serving lower-income students. Given the role of childhood in establishing food preferences and dietary consumption habits, such programs are important and can reinforce the messages imparted through nutrition education.

After the Master Settlement Agreement: trends in the American tobacco retail environment from 1999 to 2002.

Research indicates that one impact of the Master Settlement Agreement (MSA) may be to increase the focus of the tobacco industry's marketing approach on the retail tobacco environment. This article aims to provide an overview of and trends in the post-MSA American tobacco retail environment from 1999 to 2002, nationally, by region, and by locale. We examined the following specific retail tobacco environment issues: price, promotions, advertising, and placement, which stimulate or reduce demand for tobacco products. Data for this article were obtained as part of the ImpacTeen Project-A Policy Research Partnership to Reduce Youth Substance Use. Results show overall high levels of advertising, promotional activity, and price increase trends across the United States. Tobacco promotions in stores increased between 2001 and 2002. Stores in the south and rural areas tended to have the lowest prices and highest prevalence of promotions and advertising, suggesting a need for tobacco control intervention.

Commercialism in US elementary and secondary school nutrition environments: trends from 2007 to 2012.

IMPORTANCE: Schools present highly desirable marketing environments for food and beverage companies. However, most marketed items are nutritionally poor. OBJECTIVE: To examine national trends in student exposure to selected school-based commercialism measures from 2007 through 2012. DESIGN, SETTING, AND PARTICIPANTS: Annual nationally representative cross-sectional studies were evaluated in US public elementary, middle, and high schools with use of a survey of school administrators. EXPOSURES: School-based commercialism, including exclusive beverage contracts and associated incentives, profits, and advertising; corporate food vending and associated incentives and profits; posters/advertisements for soft drinks, fast food, or candy; use of food coupons as incentives; event sponsorships; and fast food available to students. MAIN OUTCOMES AND MEASURES: Changes over time in school-based commercialism as well as differences by student body racial/ethnic distribution and socioeconomic status. RESULTS: Although some commercialism measures-especially those related to beverage vending-have shown significant decreases over time, most students at all academic levels continued to attend schools with one or more types of school-based commercialism in 2012. Overall, exposure to school-based commercialism increased significantly with grade level. For 63.7% of elementary school students, the most frequent type of commercialism was food coupons used as incentives. For secondary students, the type of commercialism most prevalent in schools was exclusive beverage contracts, which were in place in schools attended by 49.5% of middle school students and 69.8% of high school students. Exposure to elementary school coupons, as well as middle and high school exclusive beverage contracts, was significantly more likely for students attending schools with mid or low (vs high) student body socioeconomic status. CONCLUSIONS AND RELEVANCE: Most US elementary, middle, and high school students attend schools where they are exposed to commercial efforts aimed at obtaining food or beverage sales or developing brand recognition and loyalty for future sales. Although there have been significant decreases over time in many of the measures examined, the continuing high prevalence of school-based commercialism calls for, at minimum, clear and enforceable standards on the nutritional content of all foods and beverages marketed to youth in school settings.

The relationship among state laws, district policies, and elementary school-based measurement of children's body mass index.

BACKGROUND: School-based measurement of children's body mass index (BMI) is a useful tool for tracking childhood obesity rates, and may be an effective intervention strategy for reducing the increasing trends in obesity. This article examines the relationship between state law, district policy, and school-level BMI measurement practices. METHODS: Data were collected during 3 school years (2006-2007, 2007-2008, 2008-2009) as part of an annual study on health policies and practices in a nationally representative sample of US public elementary schools. Data collected included school-level data via a mailed questionnaire, and district-level policies and state laws from publicly available sources. We examined whether state laws and district policies were linked to school-level BMI measurement, either directly, or via a mediation effect. RESULTS: Schools were most likely to measure student BMI if there was a state law in place (65.0% of schools) than where there was not a state law regarding BMI measurement (38.4% of schools; χ(2) = 120.91, p < .001). However, school-level BMI measurement did not differ by whether the district had a relevant policy or not (49.8% vs. 49.2%, ns). These effects held up in multivariate logistic regression models controlling for relevant school-level covariates (region, race/ethnicity, location, school size, and socioeconomic status). Schools in the south and those with a majority of White students were most likely to measure students' BMI. CONCLUSION: State laws are associated with school-level BMI measurement, and therefore may be a helpful tool in monitoring and addressing childhood obesity.