Method
To achieve the objectives of this exploratory study two study designs were employed, a cluster randomised controlled trial and semi-structured focus groups. Quantitative methods were used to test the effectiveness of MI compared to DHE and a qualitative approach employed to explore participant experience with the MI intervention.
Sample Selection
The accessible population group for the MI intervention were families of children attending preschools within the catchment area of the Arima District Health Facility (Eastern Trinidad). This Health Centre also housed the local dental clinic, staffed by Dental Nurses (the equivalent of dental therapists in the UK), who would be assisting in the research.
The sampling frame consisted of 12 preschools on a contact list for community dental outreach activity by Dental Nurses working at the Arima District Health Facility. To enable involvement of the two Dental Nurses in this research concurrent to their clinical commitments in the District Health Facility, it was decided that a maximum of six preschool would be manageable within the time-frame of this pilot study. The 6 preschools (clusters) were drawn randomly from the contact list and subsequently assigned to the test group (DHE + MI) or the control group (DHE), with 3 preschool clusters in each group. The placement of preschools in a particular study group was based on simple randomization (preschools numbered 1–6 and these numbers randomly assigned to test or control group).
Approval and Consent
Ethical approval was obtained from the Faculty of Medical Sciences Research Ethics Committee (The University of the West Indies). For the selected preschools, letters of request to be included in the study were sent to the head teacher/preschool administrator, for each preschool. When approval was obtained, packages were then hand–delivered by a dental nurse to each preschool. These packages contained information about the study and a consent form requesting parent/caregiver participation and the study questionnaire. These documents were distributed to parents/caregivers via the head teachers, who were also asked to collate the returned consent forms and completed questionnaires, for collection by the study team.
Experimental Design and MI Protocol
Control group – (Dental Health Education)
All participants (parents and caregivers) in the control group were given a 30 -min talk (as a group) on dental care of preschool children's teeth by a Dental Nurse. This talk included advice on diet, oral hygiene, fluoride use and dental attendance. At the end of the talk, participants were given a DHE leaflet reinforcing the information to take home. All participants in the control-group were given dental health products (toothpaste samples and floss) as a token of appreciation for taking part in the study. The three control group-talks included 6, 13 and 35 participants, respectively.Test group – (Motivational Interviewing & Dental Health Education)
Participants in the intervention group received a 30-min talk (as a group) based on a Motivational Interviewing approach, delivered by an MI counsellor/educator (RN) (a dentist trained in MI), assisted by a Dental Nurse. Training of the MI counsellor/educator involved a one-day course (8 h) on Motivational Interviewing and coaching skills for health professionals that included both applied (hands-on) and theoretical elements, with the theoretical materials also made available for self-study.
The group-talk was based on an MI protocol designed to aid delivery of oral health information to families with young children: Motivate your Dental Patient: A workbook -Public Health/Paediatric Edition.[18]
All participants in the test group received the same DHE information leaflet as the control group along with toothpaste samples as tokens of appreciation. All the talks took place at the preschools after a normal school day. The three test group-talks included 4, 9 and 12 participants respectively.
The outline of the study protocol and MI intervention with intended goals of each contact and the time-line is shown in Table 1.
Details of the MI Group-talk
The MI provider established rapport by showing concern and getting the parent/caregiver to talk about their child's oral health and their goals for their own and their child's oral health and oral healthcare (using open-ended questions and affirming positive efforts). Questions were themed around the following topics: Eliciting commitment to change, identifying potential problems, enhancing commitment to change, and recognizing resistance to change.
Examples of these questions were:
Tell me about your child? What do you want for your child's oral health teeth? "What are your worst fears about your child's teeth? What are you dental care challenges? How would you like things to have turned out? How could it be better? "What do you want for your child's teeth in the future?" If you could have one with wish for your child's teeth, what would it be?"
Paraphrasing the parent/caregiver's wants and desires for their child's oral health. (Using reflective listening and summarizing parent/caregiver goals). For example:
"Thank you for telling me about your child, what I understand is that you would like your child to……is that accurate?"
Presenting dental health menu options.
Participants in the MI group were shown and encouraged to share their thoughts about a written list of preventive options, termed the Dental Health Menu ( Table 2 ). These options were based on those listed in the Weinstein protocol[18] but modified to take account of participants with older children, along with items based on views expressed by parents and caregivers of preschool children from previous research in Trinidad.[17] From this list, participants were asked to choose and to commit to items they felt able to, as part of the intervention and follow-up.
Telephone Follow-up
As well as the MI group-talk at baseline, for those included in the test group, there was a follow-up of participants via telephone contact at two weeks and at one month. This was to maintain contact between participants and the MI team, problem solve, reinforce commitment and provide support. Without follow-up, new behaviours may not be tried out or the new behaviour may be tried out but not maintained because of (a) unanticipated problems (b) new behaviour was not integrated into daily routine causing relapse.[12] The telephone follow-up was undertaken by a dental nurse who had been taking field notes.
Two dental nurses were trained for this phase of the intervention by the MI counsellor/educator (RN) in a one-hour, face-to-face training session that included reviewing the written follow-up protocol. This document contained a telephone 'script' used in the Weinstein protocol. It was agreed that the script was not to be followed word-for-word but used as a basis/reference point for the telephone conversations.
Questions included in the telephone follow-up included the following: "I am calling to go over your plan (dental health menu choices)." "Let's go over parts of the plan that are a problem, sometimes a small adjustment can make a big difference" "Another mother I spoke to, had a similar problem …she tried (insert example)…it seemed to work for her family…you are the expert on your family, what do you think?"[18]
Instruments
At baseline and 4 months later, parents and caregivers were asked to complete a self-administered oral health questionnaire This instrument contained two main elements (a) Oral health knowledge, attitude and behaviour and (b) An assessment of 'readiness for change'.
Oral health knowledge, attitude and behaviour
The oral health section of the instrument included demographic information, along with a questionnaire on oral health knowledge, beliefs and attitudes, previously used in research among families with young children attending a dental hospital in Trinidad.[19] All questions in this instrument were included in the present study. Additional questions on brushing frequency (how many times in the last week did your child brush his/her teeth in the last week?), oral health self-efficacy (OHSE) and oral health fatalism (OHF) were item subscales used in a study of children aged 1–5 from low-income African American children in the USA (Detroit Dental Health Project), which were found to have good internal reliability and validity.[20,21]
The adapted instrument in the present study (i.e. combination of the Trinidad questionnaire and the question items from the Detroit questionnaire) was reviewed for face validity by the local research coordinators (RN, JN) and found to be appropriate for language and question structure.
OHSE was scored as follows: How confident are you that you can get your child's teeth brushed at bedtime in the following situations?: When under a lot of stress, when feeling low, when feeling anxious, feeling too busy, when feeling tired, worrying about things, when your child doesn't stay still when you you want to brush them, when told by your child he/she does not feeling brushing.
For each of these items the responses were recorded on a 4-point scale: (4 = Very confident to 1 = Not all confident). OHF was measured on a 5-point scale, 5 = Strongly agree to 1 = Strongly disagree, for the following statements: 'Most children eventually develop cavities', 'Cavities in Baby teeth don't matter since they fall out anyway'.The Readiness Assessment of Parents Concerning Infant Dental Decay (RAPIDD)
The parent/caregiver oral health questionnaire also included a specific instrument, the Readiness Assessment of Parents Concerning Infant Dental Decay (RAPIDD) developed by Weinstein and Reidy.[22] Based on the Transtheoretical/stages of change model (TTM), this instrument was designed to measure parent/caregiver 'readiness for change'. Using four constructs: Openness to Health Information, Valuing Dental Health, Convenience and Change Difficulty and Child Permissiveness, RAPIDD attempts to assess whether the parent/caregiver is at one of the following stages: pre-contemplative, contemplative, preparing for action, with respect to their child's oral healthcare. The RAPIDD instrument was validated in a study among families with young children (age 6 to 36 months) in the US Commonwealth of the Northern Mariana Islands, in the Pacific. Again, for use in the present study, the instrument was assessed for face validity and modified for use with a slightly older age-group (3 to 5 years) by the authors (RN, JN). This included rewording of questions relating to bottle-use. Table 3 shows the four RAPIDD constructs and corresponding construct items. It should be noted that, within the questionnaire, these items are not themed by construct but listed as statements for which the participant is asked to agree with on a 5-point Likert scale (5 = Strongly Agree, 4 = Agree, 3 = Neither agree or disagree, 2 = Disagree, 1 = Strongly Disagree). Mean scores are derived for each of the four RAPIDD constructs.
In the present study, RAPIDD data were used to assess participant's 'readiness for change' as an outcome measure of the MI intervention based on mean scores for the above-listed constructs and identified as pros and cons. As parents and caregivers weigh both the pros and cons of changing their behaviour, tipping the balance in favour of pros and reducing the cons may facilitate behaviour change. Two constructs assess pros: 'Openness to Health Information' and 'Valuing Dental Health' and two constructs assess cons: 'Convenience and Change Difficulty' and 'Child Permissiveness'.
Statistical Analysis
The Chi square test was employed for categorical variables related to oral health knowledge (baseline versus follow-up), for test and control-group. These were: causes of caries, toothbrush size, brushing position, diet/frequency of sweet snacks, toothpaste and fluoride use (significance level: p < 0.05).
Independent sample t-test was employed to assess the effect of the intervention on continuous variables related to oral health behaviours and attitudes. These were Tooth brushing frequency, Oral health Self-efficacy, Oral health fatalism, and RAPIDD constructs. Mean scores for these items were compared at follow-up between test and control-group (significance level: p < 0.05).
Qualitative Study (Focus Groups)
The present study used a focus group approach to collect qualitative data on participants' experiences with the MI intervention. Focus groups are one of several methods for acquiring qualitative data. They can be considered as an semi-structured interview with a group of people who are encouraged to interact with each other and the facilitator, using group dynamics to stimulate discussion, gain insights and generate ideas to explore a chosen topic in depth.
Focus Group Sample Selection
In liaison with the preschool head teachers/administrators, a focus group discussion was arranged for parents/caregivers from one of the three preschool (clusters) that had received the MI intervention. This took place 6 months after the end of MI intervention (i.e. last telephone follow-up). Due to the busy schedule of events in the other two preschools their head-teachers/administrators indicated that they were unavailable for inclusion in this phase of the study. All parents/caregivers from the preschool who had attended the group-talk and engaged in the follow-up were invited to participate, through the head-teacher/administrator. The venue for the focus group discussion was the preschool main classroom, after working hours, during the middle of a school week.
The focus group was run by a facilitator/moderator (RN), previously trained in qualitative methodology (26 h, didactic and practical,) and a dental nurse, who served as the assistant moderator.
Conduct of the Focus Group
The facilitator/moderator, welcomed the parent's and caregivers to the event. To obtain informed consent for participation in the focus group, the purpose and conduct of the event (focus group) was explained i.e. an open discussion (not an interview) around the theme of preschool children's dental healthcare based on the dental health group-talk and telephone calls given some months previously. It was explained that an audio recording of the discussion would be made but that all comments and opinions offered would remain anonymous and individuals would not be identified by name during transcription and reporting of the findings. It was also emphasized that all comments (positive or negative) would be considered of value. All the parents and caregivers present gave verbal consent to participate in the focus group discussion. Participants were also invited to complete a short form to record socio-demographic information.
To initiate and facilitate the discussion the moderator used a focus group topic guide (Table 4). This topic guide was designed to help explore how participants felt about receiving the MI intervention (group talk, dental health menu and telephone follow-up), along with specific issues related to making changes to oral healthcare practices and routines following the intervention. Questions in the topic guide were open-ended and not asked in a specific order but rather in response to the flow of the discussion.
The discussion was recorded on a digital audio recorder and field notes taken by the assistant moderator. At the end of the session, participants were thanked and given dental products as tokens of appreciation (toothpaste/floss samples). Light refreshments were provided before and during the discussion.
Qualitative Data Analysis
A thematic content analysis was used to analyse the qualitative data collected in the focus group session. As a first step, the focus group audio recording was transcribed into a Word document. The verbatim transcript was then numbered line-by-line for identification. After several readings of the transcript, field notes and listening to the audio recording, the data underwent a process of initial labelling of sections of the transcript by placing codes in the text margin. Similarly coded pieces of the transcript were re-assembled near to each other by cutting and pasting text sections into a new Word document. These initial codes (which could overlap) were then further developed to identify emerging early 'themes' (proto-themes) which were themselves further refined into the final themes These themes were reported in the results with supporting verbatim quotes from the transcript.
Data Trustworthiness and Reflexivity
To determine data credibility (member checking), at the end of the session participants were invited to give their opinion (off-record) as to whether the discussion had accurately documented their own experiences.[23] All focus group participants agreed that the points discussed and views presented had been a good representation of their collective and individual experiences with the MI intervention. Reflexivity in qualitative research recognises that the researcher is part of the process of producing the data and interpreting their meaning.[23,24] Furthermore, consideration was given to the facilitator/moderator having also been an active part of the MI intervention. This was not however, believed to have influenced the views expressed in the focus group discussion or subsequent interpretation of the data.
BMC Oral Health. 2015;15(101) © 2015 BioMed Central, Ltd.
