Patterns of Change in Parental Health Literacy in Relation to Children's Oral Health.

BACKGROUND: Although health literacy (HL) skills may change over time, most research treats HL as a constant, using baseline HL to predict other health-related constructs. Few studies have explored change in HL over time. OBJECTIVE: We examined person-level differences in HL trajectories. We identified subgroups (latent classes) based on longitudinal assessments of HL and examined the association of class membership with demographic and oral health variables. METHODS: We used four measurement waves of parental HL data, reflecting the risk of limited HL, collected as part of an intervention to reduce dental decay in American Indian children (N = 579 parent-child dyads at baseline). Repeated measures latent class analysis (RMLCA) models were estimated to identify subgroups of HL trajectories over time. We examined class membership in association with baseline demographics and with 36-month assessments of parental oral health knowledge, beliefs, and behaviors as well as pediatric oral health. KEY RESULTS: A four-class model best fit the data. The largest class (high HL; 49.7% of the sample) was characterized by high levels of HL at all waves. A second class (improving HL; 17.7%) improved over all waves. The remaining two classes were characterized as moderate HL (20%) and low HL (12.6%) and maintained relatively stable HL levels over time. Higher educational attainment was associated with membership in the high HL and improving HL classes. Older age among this young-adult sample and higher income also were associated with high HL class membership. Parents in the high HL and improving HL classes exhibited more favorable performance on measures of oral health knowledge, beliefs, and behavioral adherence than did those in the other classes. Class membership was not associated with pediatric oral health. CONCLUSIONS: RMLCA demonstrated person-level variability in HL trajectories. Longitudinal patterns were associated with baseline demographics and prospectively with parental oral health knowledge, beliefs, and behaviors, but not with pediatric oral health. [HLRP: Health Literacy Research and Practice. 2023;7(2):e89-e98.].

Longitudinal Association of Health Literacy with Parental Oral Health Behavior.

BACKGROUND: Prior studies suggest that parents with limited health literacy (HL) may be less likely to engage in oral health practices known to protect children's oral health. Earlier work has relied on cross-sectional data, however, so it is unclear whether HL influences parental behavior or is merely correlated with it. OBJECTIVE: We sought to clarify the impact of HL on subsequent adherence to parental oral health practices. METHODS: This secondary analysis used survey data from a randomized controlled trial designed to reduce dental decay in American Indian children (N = 579). We used path analysis to test a theoretical framework developed to clarify the mechanisms through which HL might influence parental oral health behavior. The framework proposed that HL (1) has a direct effect on parental oral health knowledge, beliefs (i.e., self-efficacy, perceived susceptibility, perceived severity, perceived barriers, perceived benefits), and behavior; (2) has an indirect effect on beliefs through knowledge; and (3) has an indirect effect on behavior through knowledge and beliefs. To test expectations regarding the temporal precedence of the constructs, we examined the association of HL at baseline with knowledge at the 12-month time point, beliefs at 24 months, and behavior at 36 months. KEY RESULTS: HL had significant direct effects on knowledge and specific beliefs (i.e., self-efficacy, perceived susceptibility, perceived barriers), but not on behavior. HL had significant indirect effects on beliefs-except perceived susceptibility-through knowledge. HL had significant indirect effects on behavior, through knowledge and beliefs. Both HL and knowledge had significant total effects on subsequent parental oral health behavior. CONCLUSIONS: HL influenced behavior measured 3 years later through its impact on parental oral health knowledge and beliefs. Our results highlight the importance of addressing HL in development of oral health promotion efforts aimed at protecting the teeth of young Native children. [HLRP: Health Literacy Research and Practice. 2021;5(4):e333-e341.] Plain Language Summary: It is unclear whether HL influences how parents care for their children's teeth. We analyzed data from a project to reduce dental decay in children. We found that HL impacted parents' oral health knowledge, beliefs, and behavior at later points in time. This suggests that HL may influence development of knowledge and beliefs that support positive behavior.

Influence of Parental Health Literacy on Change over Time in the Oral Health of American Indian Children.

In cross-sectional studies, parental health literacy (HL) is associated with children's oral health. It is unclear, however, whether HL influences pediatric outcomes. We examined the relationship of HL with change over time in parental oral health knowledge, beliefs, and behaviors, as well as pediatric oral health outcomes. We used longitudinal data from a study designed to reduce dental decay in American Indian children (N = 579). At baseline and annually for three years, parents answered questions assessing HL; oral health knowledge, beliefs, and behaviors; and pediatric oral health status. The number of decayed, missing, and filled tooth surfaces (dmfs) was computed based on annual dental evaluations. Linear mixed models showed that HL was significantly associated with all constructs, except dmfs, at their reference time points and persistently across the three-year study period. HL predicted change over time in only one variable, parents' belief that children's oral health is determined by chance or luck. HL is strongly associated with oral health knowledge, beliefs, behaviors, and status prospectively but is not a key driver of change over time in these oral health constructs.

Parental Ethnic Identity and Its Influence on Children's Oral Health in American Indian Families.

OBJECTIVES: To examine the relationship between ethnic identity and oral health knowledge, beliefs, behavior, and outcomes in American Indian families. METHODS: Secondary data were analyzed for 579 parent-child dyads in a randomized controlled trial aimed at reducing early childhood caries in a Northern Plains tribal community. Data included demographic characteristics; parental ethnic identity; oral health knowledge, beliefs, and behavior; and parental/pediatric oral health outcomes. Ethnic identity was assessed using two measures: perceived importance of tribal identity and tribal language proficiency. We examined the association of baseline ethnic identity with baseline and longitudinal oral health measures. RESULTS: At baseline, importance of tribal identity was significantly associated with several oral health beliefs, and one's locus of control measure (external-chance). Baseline scores on importance of tribal identity were also associated with one's oral heath belief (perceived severity), the same locus of control measure, and oral health knowledge and behavior over the three years of study follow up. Tribal language proficiency was not associated with any study measures at baseline, although it was associated with parental oral health status over the three years. CONCLUSIONS: Ethnic identity was associated with a range of oral health constructs expected to influence American Indian children's oral health.

Pathways Through Which Health Literacy Is Linked to Parental Oral Health Behavior in an American Indian Tribe.

BACKGROUND: Health literacy (HL) is the "ability to find, understand, evaluate and put information to use to improve decision making and, ultimately, improve health and quality of life." Parents with limited HL are less likely to follow recommended parental oral health behaviors. PURPOSE: We tested a theoretical framework designed to clarify mechanisms through which HL may influence parental oral health behavior. The framework proposed that HL: (a) has a direct effect on parental oral health knowledge, beliefs (i.e. self-efficacy; perceived susceptibility, severity, benefits, barriers), and behavior; (b) influences beliefs indirectly through knowledge; and (c) influences behavior indirectly through knowledge and beliefs. METHODS: We analyzed cross-sectional data from a randomized controlled trial designed to reduce dental decay in American Indian children (N = 521). Parents completed survey questions assessing sociodemographic characteristics, HL, and parental oral health knowledge, beliefs, and behavior. Path analysis was used to test the framework. RESULTS: HL exerted significant direct effects on knowledge and beliefs but not behavior. HL had significant indirect effects on all beliefs through knowledge. Significant indirect effects of HL on behavior occurred through self-efficacy (estimate: 0.99, 95% CI: 0.42, 1.83, p = .005), perceived barriers (estimate: 0.73, 95% CI: 0.29, 1.43, p = .010), knowledge to self-efficacy (estimate: 0.57, 95% CI: .31, 0.98, p = .001), and knowledge to perceived barriers (estimate: 0.24, 95% CI: 0.09, 0.47, p = .012). CONCLUSIONS: HL exerted an indirect effect on parental oral health behavior, with knowledge, self-efficacy, and perceived barriers being the primary constructs linking HL to behavior.

Health Literacy and Parental Oral Health Knowledge, Beliefs, Behavior, and Status Among Parents of American Indian Newborns.

OBJECTIVE: To examine the relationship between health literacy (HL) and parental oral health knowledge, beliefs, behavior, and self-reported oral health status (OHS) among parents of American Indian (AI) children. METHODS: This analysis used baseline data from a randomized controlled trial that tested an oral health intervention with parents of AI newborns. Participants were recruited in parent-child dyads (N = 579). Parents completed items assessing sociodemographic characteristics, HL, and parental oral health knowledge, beliefs, behavior, and self-reported OHS. We examined the correlation of HL with each oral health construct, controlling for parent age and income. RESULTS: On average, parents felt quite confident in their HL skills, performed well on questions assessing parental oral health knowledge, and endorsed beliefs likely to encourage positive parental oral health behaviors (e.g., confidence that one can successfully engage in such behaviors). Parents with more limited HL had significantly less knowledge, perceived cavities to be less severe, perceived more barriers and fewer benefits to recommended oral health behaviors, were less confident they could engage in these behaviors, and were more likely to believe their children's oral health was under the control of the dentist or a matter of chance (P values < 0.001). Limited HL was not associated with behavior (P > 0.05) but was linked to worse self-reported OHS (P = 0.040). CONCLUSIONS: HL was associated with parental oral health knowledge, beliefs, and self-reported OHS. Oral health education interventions targeting AI families should facilitate development of knowledge and positive oral health beliefs among parents with more limited HL skills.

Validation of Psychosocial Measures Assessing American Indian Parental Beliefs Related to Control over Their Children's Oral Health.

OBJECTIVES: To validate questionnaire items assessing American Indian (AI) parental beliefs regarding control over their children's oral health within the context of psychosocial measures and children's oral health status. METHODS: Baseline questionnaire data were collected as part of a randomized controlled trial (n = 1016) addressing early childhood caries. Participants were AI parents with preschool-age children in the Navajo Nation Head Start program. Questionnaire items assessed parental oral health locus of control (OHLOC) and agreement with beliefs indicating that they were in control of their children's oral health (internal), the dentist was in control (external powerful others), or children's oral health was a matter of chance (external chance). Exploratory factor analysis was conducted, and convergent validity was assessed using linear regression. RESULTS: Parents with more education (p < 0.0001) and income (p = 0.001) had higher scores for internal OHLOC. Higher internal OHLOC scores were associated with higher scores on knowledge (p < 0.0001), perceived seriousness and benefits (p < 0.0001), higher self-efficacy, importance, sense of coherence (p < 0.0001 for all), and lower scores for perceived barriers (p < 0.0001) and distress (p = 0.01). Higher scores for both types of external OHLOC were associated with lower scores on knowledge (p < 0.0001), perceived seriousness (p < 0.0001), and higher scores on perceived susceptibility (p = 0.01 external chance; <0.0001 powerful others) and barriers (<0.0001). Higher scores for external powerful others were associated with lower scores for importance (p = 0.04) and sense of coherence (p = 0.03). Significant associations were not found for OHLOC beliefs and children's oral health status. CONCLUSIONS: Questionnaire items addressing OHLOC functioned in accordance with the theoretical framework in AI participants.

Association of Ethnic Identity with Oral Health Knowledge, Attitudes, Behavior, and Outcomes on the Navajo Nation.

American Indians and Alaska Natives (AI/ANs) experience poor oral health. Children and adults living on the Navajo Nation have a particularly high rate of dental decay. The literature suggests that health outcomes are often associated with the strength of one's ethnic identity. We investigated the association of ethnic identity among Native parents with oral health knowledge, attitudes, behavior, and outcomes. Analyses used baseline data from a randomized controlled trial designed to reduce dental decay among AI/AN preschoolers enrolled in the Navajo Nation Head Start Program. Greater perceived importance of ethnic identity was associated with better oral health knowledge and attitudes but was unassociated with oral health behavior and was linked to worse oral health status. Parents who were better able to speak their tribal language had greater confidence in their ability to manage their children's oral health, engaged in better oral health behavior, and reported better parental oral health status.

Developing senior leadership for clinical and translational science.

The fifth in a 5-part series on the clinical and translational sciences educational pipeline, this paper focuses on strategies for developing leadership capacity among senior faculty and administrators responsible for clinical and translational science (CTS) research. Although progression in academic rank recognizes scientific excellence in research or scholarship, neither disciplinary training nor experience alone prepare senior faculty for the leadership challenges they inevitably face. Yet these faculty are increasingly responsible for multidisciplinary teams working within complex organizations with unclear or conflicting incentives that demand innovation. In academic health centers with Clinical and Translational Science Awards (CTSAs), investing in leadership often includes career development support in the CTSA education and training pillar programs. Only a few CTSAs have taken an intentional approach to developing senior leadership capacity, however, and still fewer have focused specifically on building such capacity for current CTS leaders within the context of a growing emphasis on team science. This manuscript explains the need for senior leadership training and describes an established example of such a program, the year-long Leadership for Innovative Team Science program for senior CTS researchers at the University of Colorado. The development of the program over time, topical elements, and participant perspectives are provided.

Parental psychosocial factors and childhood caries prevention: Data from an American Indian population.

OBJECTIVES: The objective of this study was to examine the association among psychological and social variables reported by American Indian parents/caregivers of preschool children and changes in their Oral Health Knowledge and Behaviors related to care of their children's teeth. We also investigated the relationship of these factors with progression of caries, as reflected by changes in their children's dmfs. METHODS: The data used for this study were collected at baseline in a clinical trial of an oral health promotion intervention comprising behavioural and clinical interventions for caries prevention delivered by tribal members on a large Southwestern American Indian reservation. Linear regression analyses were performed for changes (baseline to Year 1) in dmfs, Oral Health Knowledge and Oral Health Behavior scores, with baseline psychosocial measures, taken individually, as the independent variables. RESULTS: Parents' attitudes and beliefs were associated with increases in their Oral Health Knowledge and Behavior and also with the progression of caries for their children. When all participants were considered together, increases in children's dmfs were smaller when the caregiver had higher Internal Oral Health Locus of Control (e = -1.33, P = .004), higher Health Literacy (e = -1.55, P < .01), and higher Financial Stability (e = -4.46, P = .03), and lower scores for the Barriers subscale (e = 1.57, P < .01) of the Health Belief Model. For parents in the Intervention group, higher scores on Locus of Control, reflecting beliefs that chance, or other people determine their children's oral health, were associated with larger increases in Oral Health Knowledge (e = 1.73, P = .04) and Behaviors (e = 4.00, P = .005). CONCLUSIONS: Prevention of early childhood caries in American Indian children has proved to be especially challenging. Some of the measures identified in this report may suggest promising directions to prevention through approaches that build on competencies and skills to be learned and used within a context more broadly focused on parenting and management of health and family challenges.

Association between maternal acculturation and health beliefs related to oral health of Latino children.

BACKGROUND: This report is presenting the association of maternal acculturation, measured by preferred language, and oral health-related psychosocial measures in an urban Latino population. METHODS: A cross-sectional survey was conducted with 100 mother-child dyads from the Dental Center at the Children's Hospital Colorado, the University of Colorado. A portion of Basic Research Factors Questionnaire capturing information about parental dental knowledge, attitudes, behavior and psychosocial measures was used to collect data from the participating mothers. Descriptive statistics were calculated for demographics and psychosocial measures by acculturation. A univariate linear regression model was performed for each measure by preferred language for primary analysis followed by adjusted model adjusting for parent's education. RESULTS: The mean age of the children was 3.99 years (SD = 1.11), and that of the mother was 29.54 years (SD = 9.62). Dental caries, measured as dmfs, was significantly higher in children of Spanish-speaking mothers compared to children of English-speaking mothers. English-speaking mothers had higher mean scores of oral health knowledge, oral health behaviors, knowledge on dental utilization, self-efficacy, and Oral Health Locus of Control as compared to Spanish-speaking mothers. Univariate analysis demonstrated significant association for preference for Spanish language with knowledge on dental utilization, maternal self-efficacy, perceived susceptibility and perceived barriers. The effect of language was attenuated, but significant, for each of these variables after adjusting for parent's education. CONCLUSION: This study reported that higher acculturation measured by a preference for the English language had a positive association with oral health outcomes in children. Spanish-speaking mothers perceived that their children were less susceptible to caries. Additionally, they perceived barriers in visiting the dentist for preventive visits.

Validity of Measures Assessing Oral Health Beliefs of American Indian Parents.

OBJECTIVES: This aimed to validate measures of constructs included in an extended Health Belief Model (EHBM) addressing oral health beliefs among American Indian (AI) parents. METHODS: Questionnaire data were collected as part of a randomized controlled trial (n = 1016) aimed at reducing childhood caries. Participants were AI parents with a preschool-age child enrolled in the Navajo Nation Head Start program. Questionnaire items addressed five EHBM constructs: perceived susceptibility, severity, barriers, benefits, and parental self-efficacy. Subscales representing each construct underwent reliability and validity testing. Internal consistency reliability of each subscale was evaluated using Cronbach's alpha. Convergent validity was assessed using linear regression to evaluate the association of each EHBM subscale with oral health-related measures. RESULTS: Internal consistency reliability was high for self-efficacy (α = 0.83) and perceived benefits (α = 0.83) compared to remaining EHBM subscales (α < 0.50). Parents with more education (p < 0.0001) and income (p = 0.0002) perceived dental caries as more severe younger parents (ps = 0.02) and those with more education (ps < 0.0001) perceived greater benefits and fewer barriers to following recommended oral health behavior. Female parents (p < 0.0001) and those with more education (p = 0.02) had higher levels of self-efficacy. Parental knowledge was associated with all EHBM measures (ps < 0.0001) excluding perceived susceptibility (p > 0.05). Parents with increased self-efficacy had greater behavioral adherence (p < 0.0001), whereas lower behavioral adherence was associated with parents who reported higher perceived barriers (p < 0.0001). Better pediatric oral health outcomes were associated with higher levels of self-efficacy (p < 0.0001) and lower levels of perceived severity (p = 0.02) and barriers (p = 0.05). CONCLUSIONS: Results support the value of questionnaire items addressing the EHBM subscales, which functioned in a manner consistent with the EHBM theoretical framework in AI participants.

Fidelity of motivational interviewing in an American Indian oral health intervention.

OBJECTIVES: Assess fidelity of a motivational interviewing (MI) intervention focused on preventing early childhood caries in a cohort of American Indian mothers with newborns. METHODS: Four interventionists were trained to administer an oral health MI intervention. The MI sessions were audio recorded to enable scoring as part of fidelity studies to assess the interventionist's degree of competence in using MI principles. Evaluation of the interventionists was completed using the Motivational Interviewing Treatment Integrity (MITI) 3.1.1. which assesses global ratings and behaviour counts. Two reviewers evaluated and scored the MI sessions; a random sample of twenty per cent of the total interviews was scored by a trained reviewer and fifty per cent of the randomly selected files scored by an external expert. A total of 225 files were coded by the trained reviewer and 121 files by the external expert. RESULTS: Mean global scores for all interventionists combined were around 4.0 (expert competence). Scores for reflection to question ratios (around 0.6) were below beginner competence. Scores ranged from beginner to expert competence for open-ended questions (54%-56%), complex reflections (38%-43%) and MI-adherent statements (93%-95%). There was variation in competence for the four interventionists when analysed individually. Inter-rater reliability scores for the two reviewers ranged from fair (0.40-0.59) to good (0.60-0.74). The MI interventionist rated the best in the fidelity assessment had the worst study outcomes compared to other interventionists. CONCLUSIONS: Individual interventionists' scores for the MITI global ratings and behaviour counts reflected variation in competence and ranged from below beginner to expert levels. A higher competence level of the interventionist as assessed by the fidelity study was not related to better study outcomes.

Acculturation and Pediatric Minority Oral Health Interventions.

Immigrant populations are growing at a fast pace in the United States. Cultural variations can have implications on oral health of children from immigrant households. Length of stay in the United States and language spoken at home, proxies for measuring acculturation, are some of the crucial factors determining the level of acculturation in families. Higher acculturation generally has a positive impact on oral health utilization. Improving cultural competency of dental teams and involving the stakeholders in intervention design and implementation are some strategies that may increase the trust of ethnic minority patients and reduce barriers to access to care.

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.