Calibration and reliability testing of a novel asynchronous photographic plaque scoring system in young children.

OBJECTIVES: The Simplified Oral Hygiene Index for Maxillary Incisors (OHI-MIS) is a novel plaque scoring system adapted for young children. This study describes calibration training and testing used to establish the inter- and intra-rater reliability for OHI-MIS measured from clinical photographs. METHODS: Two raters from the Coordinated Oral Health Promotion Chicago (CO-OP) and one from the Behavioral EConomics for Oral health iNnovation (BEECON) randomized controlled trials (RCTs) underwent calibration with gold standard raters, followed by annual re-calibration. Raters from CO-OP also completed inter-rater reliability testing; all three raters completed intra-rater reliability testing rounds. Photographs were obtained from children aged 9-39 months. RESULTS: All three raters achieved greater than 0.77 Lin's Concordance Correlation (LCC) versus gold standard consensus during calibration. All three raters had LCC ≥0.83 at recalibration 1 year later. CO-OP trial raters scored 604 photos (151 sets of 4 photographs); mostly both raters were somewhat/very confident in their scoring (≥89%), describing the most photos as "clear" (90% and 81%). The CO-OP inter-rater LCC for total OHI-MIS score was 0.86, changing little when low quality or confidence photos were removed. All three raters demonstrated high intra-rater reliability (≥0.83). CONCLUSIONS: The OHI-MIS plaque scoring system on photos had good reliability within and between trials following protocol training and calibration. OHI-MIS provides a novel asynchronous plaque scoring system for use in young children. Non-clinicians in field or clinical settings can obtain photographs, offering new opportunities for research and clinical care.

Community Health Worker Asthma Interventions for Children: Results From a Clinically Integrated Randomized Comparative Effectiveness Trial (2016‒2019).

Objectives. To compare asthma control for children receiving either community health worker (CHW) or certified asthma educator (AE-C) services. Methods. The Asthma Action at Erie Trial is a comparative effectiveness trial that ran from 2016 to 2019 in Cook County, Illinois. Participants (aged 5‒16 years with uncontrolled asthma) were randomized to 10 home visits from clinically integrated asthma CHWs or 2 in-clinic sessions from an AE-C. Results. Participants (n = 223) were mainly Hispanic (85%) and low-income. Both intervention groups showed significant improvement in asthma control scores over time. Asthma control was maintained after interventions ended. The CHW group experienced a greater improvement in asthma control scores. One year after intervention cessation, the CHW group had a 42% reduction in days of activity limitation relative to the AE-C group (b = 0.58; 95% confidence interval = 0.35, 0.96). Conclusions. Both interventions were associated with meaningful improvements in asthma control. Improvements continued for 1 year after intervention cessation and were stronger with the CHW intervention. Public Health Implications. Clinically integrated asthma CHW and AE-C services that do not provide home environmental remediation equipment may improve and sustain asthma control.

Psychosocial Moderators and Outcomes of a Randomized Effectiveness Trial for Child Asthma.

OBJECTIVE: Psychosocial factors play a role in child asthma morbidity and disparities, but their impact on asthma intervention effectiveness is less understood. This study examined how child, parent, and family psychosocial factors moderated asthma response to, and changed in response to, 2 community asthma interventions among urban minority youth. METHODS: Asthma Action at Erie was a randomized comparative effectiveness trial examining a community health worker (CHW) home intervention versus certified asthma educator (AE-C) services for children aged 5-16 with uncontrolled asthma (N = 223; mean age = 9.37, SD = 3.02; 85.2% Hispanic). Asthma control was assessed via the Asthma Control Test (ACT)/childhood ACT and activity limitation. Baseline child/parent depression and posttraumatic stress disorder (PTSD) symptoms, family chaos, and social support were examined as treatment moderators. We also tested intervention effects on psychosocial outcomes. RESULTS: For parents with higher baseline depression symptoms, youth in the CHW group had greater ACT improvement by 24 months (7.49 points) versus AE-C (4.76 points) and 51% reduction in days of limitation by 6 months versus AE-C (ß = -0.118; p = .0145). For higher parent PTSD symptoms, youth in CHW had 68% fewer days of limitation at 24 months versus AE-C (ß = -0.091; p = .0102). Psychosocial outcomes did not vary by group, but parent depression, parent and child PTSD symptoms, and social support improved for all. CONCLUSIONS: CHW intervention was associated with improved asthma control among families with higher parent strain. Findings have implications for utilizing tailored CHW home interventions to optimize asthma outcomes in at-risk families.

Oral Health Behaviors in Very Young Children in Low-Income Urban Areas in Chicago, Illinois, 2018-2019.

INTRODUCTION: Because most data on oral health do not include infants and toddlers, we aimed to describe the oral health behaviors of low-income children younger than 3 years and determine factors associated with child tooth brushing. METHODS: We obtained data from the Coordinated Oral Health Promotion Chicago study, which included 420 families with children aged 6 to 36 months and their caregivers in Cook County, Illinois. We assessed child frequency of brushing from caregiver reports and objectively determined child dental plaque scores. Significant factors associated with tooth brushing frequency and dental plaque score were identified using the Least Absolute Shrinkage and Selection Operator variable selection. RESULTS: Mean child age was 21.5 (SD, 6.9) months, and only 45% of caregivers brushed their children's teeth twice per day or more. The mean plaque score was 1.9 (SD, 0.6), indicating high levels of plaque. Child brushing frequency was higher when children were older; used the correct toothpaste amount; brushed for a longer duration; and when caregivers brushed their own teeth more frequently, had more help with the overall care of the child's teeth, and had family to help. Child brushing frequency was lower for caregivers with more interference from activities of daily life. Children whose caregivers had more adult help with child brushing had better plaque scores; worse plaque scores were seen in children with higher sugary beverage and food consumption and lower household incomes. CONCLUSION: The tooth brushing behaviors of young children are strongly associated with those of their parents and with the level of family support for brushing. Interventions to improve brushing in young children should focus on the entire family.

Parent Nativity and Child Asthma Control in Families of Mexican Heritage: The Effects of Parent Depression and Social Support.

OBJECTIVE: Research has repeatedly demonstrated that parent foreign nativity has a protective effect on child asthma outcomes among Mexican Americans, but the mechanisms underlying this relationship are not well understood. The current study explored parent depression as a mediator and social support as a moderator of the parent nativity-child asthma control pathway. METHODS: Data come from the baseline sample of a trial (NCT02481986) testing community interventions for 223 children aged 5 to 16 with uncontrolled asthma. We focused on parent/child dyads of Mexican heritage (N = 165; mean age = 9.08, standard deviation = 2.94; 57.3% with Mexico-born parent). Asthma control was defined using the child and adult versions of the Asthma Control Test (ACT). Psychosocial factors included parent depression symptoms and social (instrumental, informational, and emotional) support. RESULTS: Mexican-born parents had fewer depressive symptoms (ß^ = -2.03, SE^ = 0.24) and children with better asthma control (ß^ = 1.78, SE^ = 0.24) than US-born parents, P < .0001. Analyses suggested partial mediation of the nativity-ACT path via parent depression (P < .001). An interaction between Instrumental Support and Nativity was marginally significant (ß^ = -0.10, SE^ = 0.05, P = .07), with protective effects only observed at higher support levels. Last, among Mexico-born parents, the protective nativity effects on ACT declined with increasing residential years in the United States through 12 years. CONCLUSIONS: This study is novel in identifying parent depression as one mechanism underlying the effects of parent nativity on child asthma control, but results suggest that the health advantages may depend on availability of support. Providing resources for parent depression and instrumental support (transportation, childcare) can optimize asthma interventions in this population.

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.

Implementation Lessons From a Randomized Trial Integrating Community Asthma Education for Children.

This study characterized and compared the implementation of clinically integrated community health workers (CHWs) to a certified asthma educator (AE-C) for low-income children with asthma. In the AE-C arm (N = 115), 51.3% completed at least one in-clinic education session. In the CHW arm (N = 108), 722 home visits were completed. The median number of visits was 7 (range, 0-17). Scheduled in-clinic asthma education may not be the optimal intervention for this patient population. CHW visit completion rates suggest that the schedule, location, and content of CHW asthma services better met patients' needs. Seven to 10 visits seemed to be the preferred CHW dose.

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.

Can an Instrument Validated to Assess Parent-Child Interactions in the Laboratory Setting Be Applied to Home-Based Observations?

Background: The Toothbrushing Observations Scale (TBOS) was developed in a laboratory setting to measure child and parent behaviors during toothbrushing. However, we required an instrument to assess home based behaviors. We assessed the feasibility of applying TBOS to observations of parents and their child (<3 years of age) in urban homes. Methods: Sample consisted of 36 families recruited from university and community pediatric dental/medical clinics and a Women, Infants, and Children center in Chicago as part of a pilot study for a larger clinical trial. The average age of children in our sample was 20.7 months. Most of the parent participants were mothers (90%), and 75% of the parents identified as Hispanic. Parent-child dyads were video-recorded during home-based toothbrushing activities and footage was reviewed by two independent TBOS coders. Results: The TBOS instrument consists of 12 parent and 18 child items. We were able to code five parent and ten child items. Conclusion: The feasibility of applying the TBOS measure to our study population was somewhat limited by factors related to home-based observations and the young age of children in our study. Instruments need to be validated across natural settings, such as the home, to increase the quality and accuracy of human behavioral data.

Family Chaos and Asthma Control.

OBJECTIVES: Asthma is a highly prevalent childhood chronic disease, with particularly high rates among poor and minority youth. Psychosocial factors have been linked to asthma severity but remain poorly understood. This study examined (1) relationships between parent and child depression and posttraumatic stress disorder (PTSD) symptoms, family functioning, and child asthma control in a sample of urban minority youth with uncontrolled asthma and (2) family functioning as a pathway linking parent depression and asthma outcomes. METHODS: Data were drawn from the baseline cohort of a randomized trial testing community interventions for children aged 5 to 16 with uncontrolled asthma (N = 223; mean age = 9.37, SD = 3.02; 85.2% Hispanic). Asthma control was defined by using the Asthma Control Test and Childhood Asthma Control Test, activity limitation, and previous-12-month asthma severity. Psychosocial measures included parent and child depression and PTSD symptoms, family chaos, and parent social support. RESULTS: Parent and child depression symptoms, but not PTSD, were associated with worse asthma control (ß = -.20 [SE = 0.06] and ß = -.12 [SE = -.03]; P < .001). Family chaos corresponded to worse asthma control, even when controlling for parent and child depression (ß = -.33; [SE = 0.15]; P < .05), and was a mediator of the parent depression-asthma path. Emotional triggers of asthma also mediated the parent depression-asthma relationship. CONCLUSIONS: Findings highlight family chaos as a mechanism underlying the relationship between parent depression and child asthma control. Addressing parent and child depression, family routines, and predictability may optimize asthma outcomes.

Design and baseline characteristics of a low-income urban cohort of children with asthma: The Asthma Action at Erie Trial.

OBJECTIVE: To describe the methodology of a randomized controlled trial comparing the efficacy of integrated asthma community health workers (CHW) and a certified asthma educator (AE-C) to improve asthma outcomes in low-income minority children in Chicago. METHODS: Child/caregiver dyads were randomized to CHW home visits or education in the clinic from an AE-C. Intervention was delivered in the first year after enrollment. Data collection occured at baseline, 6-, 12-, 18, and 24-months. The co-primary outcomes included asthma control using the Asthma Control Test/childhood Asthma Control Test (ACT/cACT) and activity limitation over the past 14 days. RESULTS: A total of 223 participants ages 5-16 years were randomized. The majority of children were in the 5-11 year old range (78.9%). Most caregivers (96.9%) and 44% of children were female. Approximately 85% of caregivers and children reported Hispanic ethnicity and 62.3% reported a household income of ≤ $59,000. Over half (55.7%) had uncontrolled asthma as measured by ACT/cACT; 13.9% had a normal ACT/cACT score but were uncontrolled using the Asthma Control Questionnaire and 20.2% were controlled on both measures but had received oral steroids in the past year for asthma. CONCLUSION: The Asthma Action at Erie Trial successfully recruited a largely Hispanic cohort of children with uncontrolled or high-risk asthma to study the differential effects of clinic-based AE-C and home-based CHW interventions. Strengths of the trial include its comparative effectivness design that integrates interventionists and intervention delivery into a clinical setting. Categorizing asthma control in community settings for research purposes presents unique challenges. CLINICAL TRIAL REGISTRATION: University of Illinois at Chicago Protocol Record R01HL123797, Asthma Action at Erie TrialClinicalTrials.gov Identifier: NCT02481986 "ClinicalTrials.gov Registration" register@clinicaltrials.gov.

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.