Objectives
Home visiting programs promote the education and health of Early Head Start (EHS) children and pregnant women. However, EHS\u27s oral health component is unevenly implemented. We conducted an educational intervention to improve oral health knowledge and motivational interviewing techniques among Wisconsin EHS home visitors.  Methods
A questionnaire assessing oral health-related knowledge and confidence was administered to home visitors before and after an educational session. Changes between pre/post-responses were analyzed with McNemar\u27s test and Wilcoxon Signed Rank test.  Results
After the intervention there were increases in both knowledge and confidence related to oral health communication. Knowledge increases were observed in such topics as fluoridation, dental caries, and caregivers’ role in assisting and supervising children\u27s tooth brushing.  Conclusions
A brief educational intervention was associated with increased home visitor knowledge and confidence in communicating oral health messages to EHS caregivers and pregnant women

Cao, Yumei

Flanagan, Diane

Glatt, Kevin

Okunseri, Christopher

Simpson, Pippa

Willis, Earnestine

English

epublications@Marquette

Marquette Universitye-Publications@MarquetteSchool of Dentistry Faculty Research andPublications Dentistry, School of7-1-2016Evaluation of An Oral Health Education Session forEarly Head Start Home VisitorsKevin GlattMedical College of WisconsinChristopher OkunseriMarquette University, christopher.okunseri@marquette.eduDiane FlanaganChildren's Health Alliance of WisconsinPippa SimpsonMedical College of WisconsinYumei CaoMedical College of WisconsinSee next page for additional authorsAccepted version. Journal of Public Health Dentistry, Vol. 76, No. 3 (Summer 2016): 167-170. DOI. ©2016 John Wiley & Sons, Inc. Used with permission.AuthorsKevin Glatt, Christopher Okunseri, Diane Flanagan, Pippa Simpson, Yumei Cao, and Earnestine WillisThis article is available at e-Publications@Marquette: https://epublications.marquette.edu/dentistry_fac/183NOT THE PUBLISHED VERSION; this is the author’s final, peer-reviewed manuscript. The published version may be accessed by following the link in the citation at the bottom of the page. Journal of Public Health Dentistry, Vol 76, No. 3 (Summer 2016): pg. 167-170. DOI. This article is © Wiley and permission has been granted for this version to appear in e-Publications@Marquette. Wiley does not grant permission for this article to be further copied/distributed or hosted elsewhere without the express permission from Wiley. 1    Evaluation of An Oral Health Education Session for Early Head Start Home Visitors    Kevin Glatt Department of Pediatrics, Center for the Advancement of Underserved Children, Medical College of Wisconsin, Milwaukee, WI Christopher Okunseri School of Dentistry, Department of Clinical Services, Marquette University, Milwaukee, WI Diane Flanagan Children's Health Alliance of Wisconsin, Milwaukee, WI Pippa Simpson Department of Pediatrics, Center for the Advancement of Underserved Children, Medical College of Wisconsin, Milwaukee, WI Yumei Cao Department of Pediatrics, Center for the Advancement of Underserved Children, Medical College of Wisconsin, Milwaukee, WI NOT THE PUBLISHED VERSION; this is the author’s final, peer-reviewed manuscript. The published version may be accessed by following the link in the citation at the bottom of the page. Journal of Public Health Dentistry, Vol 76, No. 3 (Summer 2016): pg. 167-170. DOI. This article is © Wiley and permission has been granted for this version to appear in e-Publications@Marquette. Wiley does not grant permission for this article to be further copied/distributed or hosted elsewhere without the express permission from Wiley. 2  Earnestine Willis Department of Pediatrics, Center for the Advancement of Underserved Children, Medical College of Wisconsin, Milwaukee, WI    Abstract Objectives: Home visiting programs promote the education and health of Early Head Start (EHS) children and pregnant women. However, EHS's oral health component is unevenly implemented. We conducted an educational intervention to improve oral health knowledge and motivational interviewing techniques among Wisconsin EHS home visitors. Methods: A questionnaire assessing oral health-related knowledge and confidence was administered to home visitors before and after an educational session. Changes between pre/post-responses were analyzed with McNemar's test and Wilcoxon Signed Rank test. Results: After the intervention there were increases in both knowledge and confidence related to oral health communication. Knowledge increases were observed in such topics as fluoridation, dental caries, and caregivers’ role in assisting and supervising children's tooth brushing. Conclusions: A brief educational intervention was associated with increased home visitor knowledge and confidence in communicating oral health messages to EHS caregivers and pregnant women. Introduction Dental caries is a common disease of childhood and the most prevalent pediatric unmet treatment need.1 Children from low-income families are disproportionately affected by caries and have limited access to dental care.2 Early Head Start (EHS) is a federally-funded program that addresses social, educational, and health needs of low-income pregnant women and children three years of age or younger. EHS programs can be based in centers or in families’ homes. Home-based EHS programs employ home visitors, who regularly visit parents to provide health-promoting services related to such topics as nutrition, safety, and child development. EHS has incorporated oral health materials into home visitor training, but these materials are not uniformly utilized3,4 and there is little documentation of home visitors’ NOT THE PUBLISHED VERSION; this is the author’s final, peer-reviewed manuscript. The published version may be accessed by following the link in the citation at the bottom of the page. Journal of Public Health Dentistry, Vol 76, No. 3 (Summer 2016): pg. 167-170. DOI. This article is © Wiley and permission has been granted for this version to appear in e-Publications@Marquette. Wiley does not grant permission for this article to be further copied/distributed or hosted elsewhere without the express permission from Wiley. 3  oral health knowledge or how they communicate with families about oral health. Uneven implementation of oral health material has been partly attributed to difficulties in communication between home visitors and families.5 Motivational interviewing (MI), a set of techniques for provider-patient interaction in which providers elicit and explore patients’ internal motivations and beliefs, can improve patients’ motivation to change behavior6 and could improve the efficacy of oral health counseling. The goal of this project was to conduct and evaluate an educational intervention that improved oral health knowledge and communication techniques among Wisconsin EHS home visitors. We hypothesized that the intervention would increase home visitors’ knowledge about oral health in early childhood and pregnancy and would also increase their confidence in communicating these topics to families. Methods Study design The study consisted of a 3-hour educational session for home visitors with oral health knowledge and MI components. The knowledge component consisted of a slide show addressing such topics as dental caries, toothbrushing technique, fluoride, and when children should visit dentists. The MI component consisted of viewing and discussing three MI-focused videos and a role-playing exercise. Videos displayed portrayals of a) poor MI technique (closed-ended questions, overly directive); b) good MI technique (asking, listening, informing, offering choices); and c) using a 1–10 scale to assess how important patients think health goals are and how confident they feel in achieving these goals. Videos were developed by a 2014 National Oral Health Conference workgroup in collaboration with Kansas Head Start. The role-playing exercise focused on open-ended questions/listening without interrupting. A questionnaire administered before the session assessed confidence in advising about oral health and knowledge about oral health for children <3 years old and pregnant women. A post-session questionnaire assessed changes in knowledge and confidence. The study was approved by the Medical College of NOT THE PUBLISHED VERSION; this is the author’s final, peer-reviewed manuscript. The published version may be accessed by following the link in the citation at the bottom of the page. Journal of Public Health Dentistry, Vol 76, No. 3 (Summer 2016): pg. 167-170. DOI. This article is © Wiley and permission has been granted for this version to appear in e-Publications@Marquette. Wiley does not grant permission for this article to be further copied/distributed or hosted elsewhere without the express permission from Wiley. 4  Wisconsin's Institutional Review Board as part of the Wisconsin “Earlier Is Better” (EIB) program. The EIB project manager asked all 22 Wisconsin EHS programs to participate in the study, of which 14 agreed. Two thousand, two hundred and twelve children <3 years old are enrolled in these 14 programs, representing 75% of Wisconsin EHS-enrolled children. Data were collected from participating sites from December 2012 to January 2015. Each site required its home visitors to attend the session. Participants were given a meal at the session and an educational toolkit containing: oral health education curriculum and flip chart; hands-on tooth brushing model; goal-setting magnet; oral hygiene supplies for entire family; oral health activities for children; and take-home educational materials. Participating programs were given toothbrushes and toothpaste for enrolled families. No other incentives were given for participation. Data collected Data collected included: a) true/false questions related to oral health in early childhood and pregnancy; b) confidence in educating caregivers on oral health (5-point Likert scale, Not at all – Completely confident); c) opinions on session's usefulness (4-point Likert scale, Strongly disagree – Strongly agree); and d) likelihood they would discuss oral health with families as a result of the training (5-point Likert scale, Very unlikely – Likely). Educational topics and questionnaire items were adapted from the Pre-Training Questionnaire for Healthcare Providers, obtained from the Maine CDC's Oral Health Program's Kids Oral Health Partnership. Knowledge topics included: use of fluoride; assisting children with tooth-brushing; putting babies to bed with bottles; cause of dental caries; and dental care in pregnancy. Confidence topics included: recognizing and evaluating risk of tooth decay; advising about dental visits/fluoride toothpaste; and making dental referrals for young children and pregnant women. Statistical analysis A McNemar's exact test was used to evaluate changes in knowledge before and after the educational session. Confidence in educating caregivers was reported as median and interquartile range (IQR). A Wilcoxon Signed Rank test was used to compare changes in NOT THE PUBLISHED VERSION; this is the author’s final, peer-reviewed manuscript. The published version may be accessed by following the link in the citation at the bottom of the page. Journal of Public Health Dentistry, Vol 76, No. 3 (Summer 2016): pg. 167-170. DOI. This article is © Wiley and permission has been granted for this version to appear in e-Publications@Marquette. Wiley does not grant permission for this article to be further copied/distributed or hosted elsewhere without the express permission from Wiley. 5  confidence before and after the educational session. Descriptive statistics were used to summarize home visitors’ opinions on the session's usefulness. Statistical analyses were performed using SAS 9.2 (SAS Inst., Cary, NC) and SPSS 20.0 (Armonk, NY: IBM Corp). P < 0.05 is considered significant. Results One hundred and eighteen Wisconsin EHS home visitors participated in the intervention and completed pre/post-questionnaires. No questionnaires were excluded. A minority of home visitors had previous training in infant/child oral health (39.3%) or maternal oral health (25.9%). Knowledge about oral health After the session, there were statistically significant improvements in short-term knowledge for five out of fourteen questions related to oral health in pregnancy and early childhood (Table 1). Significant improvements were observed in questions related to: a) effectiveness of community water fluoridation in reducing tooth decay; b) fluoride toothpaste use in children with high risk for tooth decay; c) bacterial nature of dental caries; d) adults’ role in supervising children's brushing until age 8 years; and e) children still needing help brushing after age 2 years. Table 1. Home Visitor Knowledge Before and After an Educational Intervention   % Correct before % Correct after P-value* * A McNemar's exact test was used. N/A, not applicable. Community water fluoridation reduces tooth decay 42 71 <0.001 Children with high tooth decay risk can use fluoride toothpaste 61 93 <0.001 Dental caries are caused by bacteria 80 99 <0.001 Adults should help children brush teeth until age 8 86 97 <0.005 Children need help brushing teeth after age 2 92 99 <0.01 Primary tooth development begins before final trimester 36 47 <0.08 Oral disease may progress more quickly in children with special healthcare needs 87 93 >0.11 Children need dental exams before permanent teeth come in 97 95 >0.50 NOT THE PUBLISHED VERSION; this is the author’s final, peer-reviewed manuscript. The published version may be accessed by following the link in the citation at the bottom of the page. Journal of Public Health Dentistry, Vol 76, No. 3 (Summer 2016): pg. 167-170. DOI. This article is © Wiley and permission has been granted for this version to appear in e-Publications@Marquette. Wiley does not grant permission for this article to be further copied/distributed or hosted elsewhere without the express permission from Wiley. 6    % Correct before % Correct after P-value* Caregivers should not clean pacifiers in own mouths 97 98 >0.99 Babies should not be put to bed with bottles 99 98 >0.99 Putting children to bed with milk/formula/juice harms their teeth 97 98 >0.99 Caregivers should wipe infants’ gums with soft cloth 99 99 >0.99 Tooth decay is important in young children 100 100 N/A Pregnant women should not wait until after giving birth to see dentist 97 100 N/A High preknowledge without significant improvement was observed in questions related to: a) caregivers cleaning pacifiers in their mouths; b) babies being put to bed with bottles; c) dental risks of putting children to bed with milk/formula/juice; d) children needing dental exams before permanent teeth come in; e) benefits of wiping infants’ gums with soft cloth; f) oral disease progressing more quickly in children with special health care needs; g) importance of tooth decay in young children; and h) pregnant women not waiting to see dentists until after delivery. Low preknowledge without significant improvement was seen in a question related to primary tooth development beginning before the final trimester. Confidence in educating caregivers about oral health After the session, there were significant improvements in eight out of eight questions related to confidence in educating caregivers about oral health (Table 2). In addition, nearly all home visitors after the session Agreed or Strongly Agreed that they: knew how to access community oral health resources (97.5%); could assist families with identifying oral health barriers and goal setting (97.4%); and had acquired useful knowledge and skills from the training (96.9%). Most indicated they would be Likely to: help families connect with local dentists (85.3%); regularly discuss oral health with families (85.5%); and encourage families to discuss oral health with medical providers (85.3%). Table 2. Home Visitor Confidence Before and After an Educational Intervention   Median (IQR) confidence before Median (IQR) confidence after P-value* *A Wilcoxon Signed Rank test was used. (1 = Not at all, 2 = not very, 3 = somewhat, 4 = very, 5 = completely). NOT THE PUBLISHED VERSION; this is the author’s final, peer-reviewed manuscript. The published version may be accessed by following the link in the citation at the bottom of the page. Journal of Public Health Dentistry, Vol 76, No. 3 (Summer 2016): pg. 167-170. DOI. This article is © Wiley and permission has been granted for this version to appear in e-Publications@Marquette. Wiley does not grant permission for this article to be further copied/distributed or hosted elsewhere without the express permission from Wiley. 7    Median (IQR) confidence before Median (IQR) confidence after P-value* Recognizing early childhood tooth decay 3 (2, 3) 4 (4, 4) <0.001 Evaluating a child's risk of future tooth decay 3(2, 3) 4 (3.75, 4) <0.001 Advising caregivers about children's oral hygiene 3 (3, 4) 4 (4, 5) <0.001 Advising caregivers about children's dental visits 4 (3, 4) 4 (4, 5) <0.001 Advising caregivers about children's use of fluoride toothpaste 3(2, 4) 4 (4, 5) <0.001 Making dental referrals for infants/children 4 (3, 4) 4 (4, 5) <0.001 Making dental referrals for pregnant women 4 (3, 4) 4 (4, 5) <0.001 Advising pregnant women about their oral health 3 (3, 4) 4 (4, 5) <0.001 Discussion Community-based oral health programs that utilize pre-existing home visitors can provide cost-effective oral health support and education to families with young children who do not receive dental care.7 This project assessed a brief educational intervention that educated home visitors about oral health and motivational interviewing techniques, with the goal of improving home visitors’ capacity to provide oral health support to families. We observed a significant increase in home visitors’ knowledge and confidence related to oral health communication as a result of the session. Before the session, the majority of home visitors did not feel confident discussing oral health and had variable levels of knowledge about oral health, supporting previous observations.3 The observed increases in confidence are important as they may result in EHS home visitors more frequently and effectively deploying knowledge gained in oral health sessions. The motivational interviewing training could also be valuable, as MI can be more effective than traditional counseling at reducing rates of caries8 and severity of caries9 in EHS and other underserved populations, and could also improve the efficacy of other home visitor-caregiver interactions. This brief intervention could be replicated elsewhere at low cost. Limitations of this study include social desirability bias potentially influencing responses and not testing long-NOT THE PUBLISHED VERSION; this is the author’s final, peer-reviewed manuscript. The published version may be accessed by following the link in the citation at the bottom of the page. Journal of Public Health Dentistry, Vol 76, No. 3 (Summer 2016): pg. 167-170. DOI. This article is © Wiley and permission has been granted for this version to appear in e-Publications@Marquette. Wiley does not grant permission for this article to be further copied/distributed or hosted elsewhere without the express permission from Wiley. 8  term knowledge retention. The intervention's ability to affect pediatric dental caries outcomes will be assessed in the future. References 1Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America's children. Pediatrics. 2000;105:989-97.  2Edelstein B. Disparities in oral health and access to care: findings of national surveys. Ambul Pediatr. 2002;2(2):141-7.  3Mathu-Muju KR, Lee JY, Zeldin LP, Rozier RG. Opinions of early head start staff about the provision of preventive dental services by primary medical care providers. J Public Health Dent. 2008;68(3):154-62.  4Kranz AM, Rozier RG, Zeldin LP, Preisser JS. Oral health activities of Early Head Start and Migrant and Seasonal Head Start programs. J Health Care Poor Underserved. 2012;23(3):1205-21.  5Mofidi M, Zeldin LP, Rozier RG. Oral health of early head start children: a qualitative study of staff, parents, and pregnant women. Am J Public Health. 2009;99(2):245-51.  6Rollnick S, Miller WR, Butler CR. Motivational interviewing in health care: helping patients change behavior. New York: Guilford Press; 2008.  7Wilson LB, Debaryshe B, Singh M, Taba S. Evaluating two oral health video interventions with early head start families. Int J Dent. 2013;2013:1-9. doi: 10.1155/2013/437830  8Weinstein P, Harrison R, Benton T. Motivating mothers to prevent caries: confirming the beneficial effect of counseling. J Am Dent Assoc. 2006;137(6):789-93.  9Harrison RL, Veronneau J, Leroux B. Effectiveness of maternal counseling in reducing caries in Cree children. J Dent Res. 2012;91(11):1032-7.   

Evaluation of An Oral Health Education Session for Early Head Start Home Visitors

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Evaluation of An Oral Health Education Session for Early Head Start Home Visitors

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