Oral health promotion practices: a survey of Florida child care center directors

Oral health promotion practices: a survey of Florida child care center directors Background: To understand the oral health promotion practices (OHPPs) in Florida licensed childcare centers (CCCs), we surveyed the childcare center directors (CCCDs) employed at these centers. We determined if CCC’s affiliation with Early Head Start/Head Start (EHS/HS) programs was associated with the number of OHPPs implemented. Methods: For this cross-sectional study we emailed a pretested 45-item online survey to unduplicated email addresses of 5142 licensed CCCDs as listed in the publicly available Florida Department of Child and Family services database. Univariate and bivariate analyses were conducted. In addition, a Poisson regression model predicting higher numbers of OHPPs implemented was conducted. Results: A response rate of 19.4% was estimated. CCCDs reporting to implement a higher number of OHPPs in their CCCs were more likely to have longer work experience (b = 0.006, 95% CI: 0.001,0.012 p = 0.03), work in EHS/HS affiliated centers (b = 0.7, 95%CI: 0.48,0.91) p < 0.001), and have more positive attitudes about pediatric oral health (b = 0.08, 95%CI: 0.05, 0.10) p < 0.001). CCCDs with more self-perceived barriers reported implementing a lower number of OHPPs (b = − 0.046, 95% CI: -0.09, − 0.003 p = 0.035) compared to their counterparts. Conclusions: A significant association between a CCC’s affiliation with EHS/HS programs and the number of OHPPs implemented was observed. In addition, CCCD’s years of experience, attitudes towards oral health, and self-perceived barriers in implementing OHPPs were also associated with the number of OHPPs implemented. Keywords: Oral health, Health promotion, Day care, Child care centers, Dental caries, Prevention, Head start, Early head start Background programs can be implemented in these settings to pro- The number of child care facilities in the U.S. rose from mote the health of the enrolled children. 262,511 in 1987 to 766,401 in 2007, indicating an in- One significant public health problem is an ongoing creasing trend in the establishment of such facilities [1]. epidemic of dental caries in the U.S. children. The There were 32.7 million children in ‘out-of-home’ child 2011–2012 National Health and Nutrition Examination care facilities in year 2011, of which most (20.2 million) Survey data showed that at least 40% of 2 to 8 year old were aged 5–14 years; while the remaining 12.5 million children experienced dental caries in their primary teeth, were aged 0 to 4 years [2]. Preschoolers of employed and with at least 14% having untreated tooth decay, suggest- non-employed mothers spent approximately 36 h and ing that despite needing dental care, it was not received 21 h respectively per week in these facilities [2]. Because [3]. Approximately 21% of children ages 6 to 11, and a significant proportion of children spend so much time 53% of adolescents aged 12 to 19 years had experienced in these facilities, health intervention and promotion dental caries [3]. This national data suggests that children develop dental caries all through their childhood. * Correspondence: Vinodh.Bhoopathi@temple.edu Since many children spend a portion of their day in Department of Pediatric Dentistry and Community Oral Health Sciences, CCCs, centers provide an ideal setting to adopt mea- Temple University Maurice H. Kornberg School of Dentistry, 3223 N Broad sures to prevent dental caries, especially since most Street, Philadelphia, PA 19140, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 2 of 8 children enrolled in CCCs fall into the susceptible age Institution Review Board (IRB) (Protocol number: range for dental caries. CCCs and childcare center direc- CGG2013–19). The target population for this study was tors (CCCDs) could take an active role to prevent dental CCCDs working in licensed CCCs within the State of diseases and promote oral health of all children enrolled Florida. A publicly available database comprising of un- in these centers by educating children and their parents duplicated names and email address of Florida CCCDs about the importance of maintaining proper oral health, (n = 5142) was retrieved from the Florida Department of and adopting good oral health promotion practices Children and Families website in January 2014. Eight (OHPPs) [4]. hundred and seventy seven CCCDs responded, 53 opted The American Academy of Pediatric Dentistry (AAPD) out, and 631 email addresses were invalid. The overall recognizes the importance and impact of oral health survey response rate was estimated at 19.4% (877/4511). promotion within CCCs, based on children’s increased utilization of and time spent in these facilities for daily Survey instrument care [5]. The AAPD released a set of oral health guide- The authors developed the 45-item survey by adapting lines addressing dental disease prevention and oral questions from previously tested and validated surveys health promotion in out-of-home child care settings tar- [11–13]. AAPD oral health policies for CCCs [5] were geting CCCs, pediatric dentists, other health care profes- also used to construct questions to assess OHPPs imple- sionals, legislators and policy makers [5]. This policy mented in the CCCs. A group of five pediatric dentists encourages CCCs to implement oral health promotion provided detailed feedback on the structure and content practices (OHPPs) to reduce a child’s risk of acquiring of the first draft of the survey. The second draft of the early childhood caries and the risk of dental trauma modified survey was pretested with 10 CCCDs in Bro- within their centers. ward county, Florida. The survey was pilot tested Very few studies have assessed the oral health related through cognitive interviews using the concurrent think policies and regulations in daycare or childcare centers aloud method with probes [14]. These procedures we in the U.S. [6–8]. Little is known about licensed CCCs believe improved the content and face validity of the in the state of Florida, and the type of OHPPs imple- survey. mented within these centers. Florida CCCs provide a unique opportunity to explore oral health promotion practices because children in Florida experience poorer Data collection oral health and lack adequate dental care access com- The pilot tested survey was uploaded on the Survey pared to children in many other states [9]. Therefore Monkey® online platform (www.surveymonkey.com). We our study surveyed child care center directors (CCCDs) used Dillman’s guidelines such as: 1) repeated contacts, employed in Florida licensed CCCs to determine which 2) varying messages across reminders, 3) caution to of the 8 selected AAPD recommended OHPPs were minimize spam, and 4) testing the compatibility of the already implemented, and the factors associated with a online surveys on different devices and softwares, to higher number of OHPPs implemented. Because evi- contact the CCCDs and boost the responses. [15]. For dence [10] shows that children in CCCs affiliated with repeated contact, we included: (1) an introductory email Head Start [HS] programs are significantly more likely informing the CCCDs about the upcoming survey; (2) to receive health care screenings and consultations an email with a message about the intent of the survey, compared to non-HS programs, we tested if there was why they were selected to be part of the study, and the any association between number of OHPPs imple- importance of their participation; and (3) reminder mented and the CCC’s affiliation with Early Head Start/ emails, sent every 2 weeks intervals (a total of 3 re- Head start (EHS/HS) programs. EHS/HS programs are minders), on early Monday morning hours with person- federal programs that promote school readiness among alized links, to both partial and non-respondents over a low-income children 0 to 5 years of age. These pro- 6-week period. We varied the content of the email mes- grams offer comprehensive early child hood education, sage with all reminders to vary the stimulus across email health care services, nutrition, and parental involve- contacts. To minimize the likelihood of the online sur- ment services. Many EHS/HS programs are based in vey being flagged as spam we used plain text messages, preschools, and others are located in licensed childcare instead of HTML messages. And finally, we tested the centers or family childcare homes. online survey on iphones, androids, desktops, and differ- ent software and hard ware configurations. The online Methods version of the survey was also tested for operational and Study sample typological issues. The survey was initially sent to the This cross sectional study was approved by the Nova sample in January 2014, and was kept open until the end Southeastern University Health Professions Division of March 2014. Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 3 of 8 Independent variables promotion topics; 6) Insufficient space to implement OHPPs; 7) Inadequate time to implement OHPPs; 8) In- Demographic variables Questions were asked about fection control concerns; and 9) other (open response). (but not limited to) CCCDs age, gender, race, ethnicity, All checked responses (coded as 1) were summed to- highest form of education completed, annual income, gether to derive a composite SPB score (ranging from 0 years of experience as a CCCD, and if they had a child to 9), with higher scores indicating that CCCDs had of their own. greater difficulty implementing OHPPs in their centers. Pediatric oral health knowledge (knowledge) Three Affiliation with EHS/HS programs (main independ- questions/statements assessing the CCCD’s knowledge ent variable) CCCDs were asked using a check box op- about pediatric oral health, were adapted from a previ- tion to choose if their center was affiliated with EHS/HS ous study [11]. The first statement specified that the par- programs or not. A checked response meant that CCCD ents should start cleaning a child’s mouth at the age of 1 was at a center affiliated with EHS/HS programs. (True or False response). The correct answer to this question was False, because cleaning children’s teeth Main outcome variable should begin as soon as the first tooth erupts. The sec- ond True/False statement indicated that a child’s first Oral health promotion practices (OHPPs) CCCs im- dental visit should be at 2 years. The correct answer is plementation of OHPPs, as recommended by the False because children should have a first dental office AAPD’s “Policy on Oral Health in Child Care Centers” visit at the age of 1. The third statement asked the re- [5] was measured by asking 8 binary option (yes/ no) spondents to correctly choose the most common questions. In order to accommodate the time constraints chronic childhood disease for children younger than and to prevent potential overlap between OHPPs, re- 7 years old from four possible responses (Asthma, Hay searchers developed questions for only 8 out of a pos- Fever, Tooth decay, and Chicken Pox). The correct an- sible 14 AAPD recommended OHPPs. The decision to swer for this question was tooth decay. Correct answers include only 8 of the 14 AAPD recommended OHPPs were assigned a score of 1 and were summed to create a was made based on the feedback received from 5 composite knowledge score (range 0 to 3). Higher com- pediatric dentists who provided feedback on the content posite scores indicated that CCCDs had a higher level of and structure of the survey. The questions asked the pediatric oral health knowledge. CCCDs whether the center he/she was employed at: 1) had an oral health consultant; 2) regularly maintained Attitudes towards pediatric oral health (attitudes) A dental records for enrolled children; 3) had training or 5-point Likert scale (Strongly Agree to Strongly Dis- educational programs for staff about traumatic dental in- agree; coded as 1 to 5) was used to rate the following juries 4) had an onsite dental emergency manual; 5) attitude-based statements: 1) Cleaning baby teeth is not regularly distributed oral health promotion materials to important because they fall out anyway; 2) My center parents; 6) provided optimally fluoridated water for the has too many activities to devote any time to dental children; 7) promoted the dental home concept to par- health; 3) Teaching children younger than 3 years about ents; and 8) encouraged children to brush their teeth dental health is too difficult; and 4) I don’t believe that after meals or snacks. All “yes” responses were consid- the activities that we provide in the center will prevent ered positive responses, and were given a score of 1, cavities [12]. A composite attitude score (range 0 to 20) while “no” responses were coded as 0. The responses was derived by summing the answers with higher scores were summed to derive a composite OHPS score (Score indicating positive attitudes towards promoting chil- range: 0 to 8) with higher scores indicating more OHPS dren’s oral health. An acceptable internal consistency implemented by CCCs. (Cronbach’s alpha = 0.706) was estimated for the likert scales measuring attitudes. Analyses Data analyses were performed using the version 9.3 of Self-perceived barriers (barriers) Possible barriers to the SAS statistical analysis software (SAS Institute, Inc. implementing OHPPs were listed with a check box op- Cary, N.C.). Alpha coefficients were performed to test tion. CCCDs could check any of the items that apply. reliability between items included in the attitude-based The list of barriers were: 1) Insufficient funding to pro- questions. We conducted descriptive statistics to under- mote pediatric oral health; 2) Parents’ negative attitudes stand the characteristics of the study sample. The fol- towards child safety and oral health; 3) Parental cultural/ lowing variables were described through frequencies and religious barriers; 4) Parents’ language barriers; 5) Insuf- percentages: CCCD’s age, gender, ethnicity, race, educa- ficient training of center staff about oral health tion, annual income, having a child of their own (being a Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 4 of 8 parent), and the center’s affiliation with EHS/HS pro- answered “False”. Only 2 in 5 CCCDs correctly answered grams. The following variables were described through that the child’s first dental visit should not be at 2 years. means and standard deviation: CCCD’s age, years of ex- However, an overwhelming 85% of the respondents cor- perience working at a CCC, knowledge, attitudes, bar- rectly identified that tooth decay or cavities is the most riers, and the self-reported number of OHPPs common childhood disease. implemented in their center. Bivariate comparisons were The mean attitude score (16.8 ± 2.7) suggested that conducted using chi-square tests and independent stu- CCCDs had positive attitudes towards pediatric oral dent t-tests to understand differences in the proportion health. Most of the respondents (94%) believed that of CCCDs reporting OHPPs implementation, and the cleaning baby teeth was very important. Only 9% felt overall number of OHPPs implemented in CCCs. One that that there were too many activities at the center to Poisson regression model was created which predicted devote any time to children’s dental health. Most (87%) the number of OHPPs implemented in Florida CCCs. felt that teaching children younger than 3 about the im- We included all independent variables explained above portance of oral health was not difficult. More than 65% as covariates. Multi-collinearity diagnostic analysis was believed that providing oral health promotion activities performed to assess collinearity between the predictor in CCCs will prevent dental caries. variables that were included in the regression model, CCCDs did not perceive that there were too many bar- and none was detected. To assess the fit of the poisson riers to implementing OHPPs in their centers (mean regression model, we used the goodness-of-fit SPB score: 1.55 ± 1.64). Funding issues (38.5%) and lack chi-squared test. of oral health promotion training for staff (32.7%) were the most frequently reported self-perceived barriers by Results CCCDs. Less frequent barriers were lack of time to ad- The mean age of the CCCD respondents was 48.5 ± dress oral health (24.7%), infection control issues 10.5 years and they had mean years of experience of (15.2%), lack of space to promote adequate oral health 11.6 ± 9.3 years. A majority of the study participants (14.1%), and negative parental attitudes (11.6%). Few were women (96%) and belonged to the White race CCCDs perceived parent’s language barriers (6.6%), cul- (74%). Approximately 19% of the sample was Hispanics. tural issues (5.4%), or other issues (2.5%) to be signifi- The majority (65%) reported having a college degree or cant barriers to providing OHPPs in their center. higher. More than 60% reported earning an annual in- Figure 1 illustrates the percentage of respondents come of less than $50,000, with just over 20% reporting reporting about the implementation of 8 OHPPs in their an income of $50,000 and above. Only 5% of the centers. Slightly more than half of CCCDs reported that responding CCCDs reported that their center was affili- they promote the dental home concept to parents (53%) ated with EHS/HS programs. and provide optimally fluoridated water to children On average, participants answered only one knowledge (53%), while the least implemented OHPPS were having question out of 3 correctly [Knowledge score: 1.3 ± 0.8 an oral health emergency manual on site (8%) and main- (mean ± SD)]. When asked if age 1 was the correct age taining children’s dental records (5%). On average, to initiate cleaning a child’s teeth, only 1 in 5 correctly CCCDs reported implementing only 2.1 ± 1.6 (mean ± Fig. 1 Percentage of childcare directors reporting implementation of certain oral health promotion practices in their centers Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 5 of 8 SD) out of 8 possible AAPD recommended OHPPs in Poisson regression analysis their CCCs. The adjusted Poisson regression model predicting higher number of OHPPs implemented in Florida licensed CCCs is showninTable 2. CCCDs employed at a center affiliated Bivariate analysis with EHS/HS programs reported implementing a higher Tables 1 compares the differences in number of OHPPs number of OHPPs compared to CCCDs at centers not affil- implemented by selected characteristics of CCCDs. No iated with EHS/HS programs (b = 0.7, 95%CI: 0.48,0.91) p significant differences in OHPPs implemented were ob- < 0.001). The results also confirmed that CCCDs reporting served by ethnicity, income, and having a child of their higher number of OHPPs implemented in their centers own. Male CCCDs reported a significantly higher num- were more likelytohavelongerworkexperience(b=0.006, ber of OHPPs implemented compared to female CCCDs 95% CI:0.001, 0.012 p = 0.03), and have more positive atti- (p= 0.02). Those belonging to a non-White racial back- tudes about pediatric oral health (b = 0.08, 95%CI: 0.05, ground (p= 0.001), and those with a college degree (p 0.10) p < 0.001). CCCDs who had more self-perceived bar- = 0.03) and above reported implementing a significantly riers in implementing OHPPs reported that their centers higher number of OHPPs compared to their counter- had implemented significantly lower number of OHPPs (b parts. Table 2 compares CCCs affiliated with EHS/HS = − 0.046, 95% CI: -0.09, − 0.003 p = 0.035). The goodness programs to unaffiliated centers. More EHS/HS affiliated of fittestprovedthatthe Poissonregressionmodel fitthe CCCDs consistently reported implementing 7 OHPPs data reasonably well because the test was not statistically compared to their counterparts, with the exception of significant (p = 0.094). one OHPP. Directors in EHS/HS affiliated centers were as likely (52%) to report providing clean optimally fluori- Discussion dated water throughout the day as directors in centers Understanding the oral health promotion practices in that are not affiliated (47%). Overall, the directors in Florida licensed CCCs is important because these cen- centers affiliated with EHS/HS programs reported to ters can be utilized as alternate non-traditional settings have implemented a significantly higher mean number to promote optimal oral health of children. So we con- (5.1 ± 2.3) of OHPPs compared to those in centers not ducted a survey of CCCDs in Florida licensed CCCs to affiliated (1.9 ± 1.8). examine whether their center implemented any OHPPs, and if their center’s affiliation with EHS/HS programs af- fected the number of OHPPs implemented. Of the 8 OHPPs assessed, our findings indicate that, Table 1 Mean differences in OHPPs implemented by selected on average, CCCDs reported implementing very few CCCD characteristics OHPPs in their centers, suggesting that OHPPs may not Variable OHPPs (mean ± SD) p-value adequately practiced in these centers. More than 80% of Gender the CCCDs reported that their enrollees did not brush Male 2.79 ± 2.2 0.02 after meals, their center lacked an oral health consultant and oral health emergency manuals, the staff were not Female 2.04 ± 1.6 trained in traumatic dental injuries, and did not main- Race tain children’s dental records. This indicates that, based White 1.95 ± 1.5 0.001 on the CCCDs’ reports, AAPD recommended oral health Non-White 2.39 ± 1.9 prevention and promotion activities were not frequently Ethnicity practiced in licensed Florida CCCs. In fact, a substantial Hispanics 2.24 ± 1.7 0.15 number of children younger than 5 years old were en- rolled in these centers at the time of our study (more Non-Hispanics 2.02 ± 1.6 than 80%), which is problematic because this age group Income has high dental caries risk and oral health promotion > =50,000 2.04 ± 1.5 0.92 should already be initiated. At least in this study, we did < 50,000 2.03 ± 1.6 not find any association between CCCD’s oral health Education knowledge and the number of OHPPs implemented. College degree and above 2.16 ± 1.7 0.03 However, possessing correct oral health knowledge and high oral health literacy is important for CCCDs to prac- < College degree 1.89 ± 1.4 tice appropriate OHPPs not only for themselves but also Have Child Of your own to implement into that childcare system that will benefit Yes 2.04 ± 1.6 0.9 the enrolled children. Therefore Florida CCCDs need No 2.06 ± 1.7 more education about the importance of implementing Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 6 of 8 Table 2 Factors predicting higher number of oral health promotion practices implemented in Florida child care centers Variable Paramester 95% CI p-value estimate Age 0.006 (−0.001, 0.013) 0.95 Years of experience (Higher number) 0.006 (0.0006, 0.012) 0.03 Gender (Male versus Female) 0.093 (−0.224, 0.41) 0.57 Race (White versus Non-Whites) −0.08 (−0.218, 0.057) 0.25 Have a Child of your own (Yes Versus No) 0.074 (−0.073, 0.22) 0.33 Income (< 50,000 versus > = 50,000) −0.009 (−0.15, 0.132) 0.90 Education (college degree and above versus Less than college degree) 0.033 (−0.103, 0.17) 0.64 Type of Center (Early Head Start Versus Non-Early Head Start) 0.7 (0.48, 0.914) <.0001 Oral Health Knowledge (Higher number) 0.001 (−0.08, 0.08) 0.98 Attitudes (Higher number) 0.08 (0.05, 0.103) <.0001 Barriers (Higher number) −0.046 (− 0.09, − 0.003) 0.035 OHPPs within their CCCs, along with the long-term im- insufficient staff time for pediatric oral health promo- pact it can have on a child’s overall health and tion. Previous literature has shown that these three ele- well-being. However, it was encouraging to find that ments are critical to the success of any health promotion most participants (67%) reported that they might imple- or disease prevention programs in CCCs. Therefore we ment OHPPs in the upcoming year. recommend that CCCDs identify strategies to overcome To test our hypothesis and to determine factors asso- these three barriers to health promotion. Additional ciated with more implemented OHPPs in Florida CCCs, open-ended responses provided insights into other po- we conducted an adjusted Poisson regression model that tential barriers faced by CCCDs when implementing yielded interesting results. Our study found that CCCDs OHPPs including: dentists rarely treating and educating working in EHS/HS affiliated centers implemented more children younger than 3 years, few community dentists, OHPPs compared to their counterparts (p < 0.001). We and there is no need to enforce oral health promotion at conclude that there was a significant association between the center because it is not required for Florida’s the number of OHPPs implemented and the center’s af- licensure. filiation with EHS/HS programs. Literature supporting Ours is the first study to survey CCCDs in Florida on this result exists, with HS centers promoting health con- relevant OHPPs in their centers. Therefore our study siderably more frequently than non-HS centers [10]. In a highlights for the first time, the status of licensed CCCs multi-state survey a higher proportion of responding in Florida and the lack of adequate oral health promo- CCCDs in HS centers reported consulting health profes- tion in these settings. Limitations of this study include sionals and screening for health problems in enrolled but are not limited to low response rate, use of a con- children, compared to their counterparts. This is due to venience sample, and induced bias due to selective par- greater awareness about pediatric health, and CCCDs in ticipation. Therefore our study results should be HS centers may attach greater importance to children’s interpreted with caution. Only 5% of the respondents re- health issues [10]. More experienced CCCDs may have ported working in EHS/HS affiliated centers compared been more confident and efficacious compared to inex- to their counterparts (95%). A previous study showed perienced CCCDs, and therefore may have implemented very similar findings, with only 10% of the responding more OHPPs. CCCDs with positive pediatric oral health CCCDs reporting to work at HS affiliated centers [10]. promotion attitudes were more likely to report imple- We did not find information about the proportion of li- menting OHPPs in their centers. Evidence suggests that censed CCCs in Florida that were affiliated with EHS/ those with more positive attitudes about health mainten- HS programs and therefore we were unable to determine ance are more likely to adopt and practice healthy be- if non-EHS/HS CCCDs were more or less likely to par- haviors for their own well-being [16]. Prior research ticipate in the survey compared to their counterparts. A supports the idea that more barriers (perceived and real) very small proportion of the respondents were males. impede prevention program implementation [17]. The Other types of childcare facilities, such as non-licensed most frequently reported barriers to implementing CCCs, group childcare homes or family child care OHPPs by study participants were: 1) insufficient fund- homes, were not explored because we did not have ac- ing to implement oral health programs, 2) insufficient cess to these facilities. Understanding the demographic staff training about oral health promotion, and 3) differences between respondents and non-respondents Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 7 of 8 could not be accomplished because the researchers did manuscript. RJ: Study design, data analysis, and critical editing of the manuscript for important intellectual content. All authors read and approved not manually track the participants as deemed by the the final manuscript. IRB guidelines. Due to the limited funds to execute this study, postal surveys were not economically feasible. Authors’ information Dr. Vinodh Bhoopathi, was an Assistant Professor at Nova Southeastern Because the EHS/HS affiliated centers implement University College of Dental Medicine, and the thesis committee chair for Dr. more OHPPs, we believe that EHS/HS programs may Joshi’s thesis when this study was conducted. Currently Dr. Bhoopathi is an serve as a model that can be integrated into non-EHS/ Assistant Professor at the Temple University Maurice H Kornberg School of Dentistry, Philadelphia, PA. Dr. Ajay Joshi was a pediatric dental resident at HS affiliated programs. Because many children receive Nova Southeastern University College of Dental Medicine when this thesis daycare in CCCs, it is imperative that policy makers and study was conducted. Currently he is an Assistant Clinical Professor at State Departments of Health focus on policies and regu- Indiana University School of Dentistry and maintains his private practice in Marion, IN. Dr. Romer Ocanto is Associate Professor, and Chair of Pediatric lations that will improve the integration of OHPPs into Dentistry at Nova Southeastern University. Dr. Robin J. Jacobs is Associate these settings. For example, in the State of Florida, the Professor at Nova Southeastern University College of Osteopathic Medicine child care licensing program is a component of the ser- at the time of the study. Currently she is an Associate Professor at Baylor College of Medicine. Address correspondence to Dr. Bhoopathi. E-mail: vices provided by the Department of Children and Fam- Vinodh.Bhoopathi@temple.edu ilies. This program through regulations and consultation ensures that licensing requirements are met by the Ethics approval and consent to participate childcare facilities thus preventing operation of sub- This study was approved by the Institution review board (IRB) at the Nova Southeastern University Health Professions Division (Protocol: CGG2013–19). standard childcare programs. Such departments can add Participants were informed through an email message about the objectives mandatory regulations related to maintaining certain of the study and that by clicking the online survey link they were consenting oral health standards in CCCs. By doing so, optimal oral to participate in the study. They were also informed that their participation is voluntary and anonymous, and that they may choose anytime to not health in children can be achieved by all CCCs. Child participate in the study. care centers are non-traditional alternate settings where new disease prevention and health promotion programs Competing interests Dr. Bhoopathi is an Associate Editor of the BMC Oral Health Editorial Board. can be implemented to improve the health of enrolled Other author(s) declare no competing interests. children. These settings are excellent resources to apply oral health intervention programs, provided there are Publisher’sNote few barriers. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Conclusions Author details We conclude that affiliation with EHS/HS programs is Department of Pediatric Dentistry and Community Oral Health Sciences, associated with the number of OHPPs implemented li- Temple University Maurice H. Kornberg School of Dentistry, 3223 N Broad censed Florida licensed CCCs. In addition, CCCDs years Street, Philadelphia, PA 19140, USA. Pediatric Dentistry Department, Indiana University School of Dentistry, 1121 W. Michigan Street, Indianapolis, IN of experience, attitudes towards oral health, and 46202, USA. Department of Pediatric Dentistry, Nova Southeastern University self-perceived barriers in implementing OHPPs were College of Dental Medicine, 3200 S University Drive, Fort Lauderdale, FL also associated with number of OHPPs implemented. 33328, USA. Department of Family and Community Medicine – Research Programs, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston, Abbreviations TX 77098, USA. AAPD: American Academy of Pediatric Dentistry; CCCDs: Child care center directors; CCCs: Child care centers; EHS/HS: Early Head Start/ Head Start; Received: 25 October 2017 Accepted: 22 May 2018 HS: Head Start; IRB: Institution Review Board; OHPPs: Oral health promotion practices References Acknowledgements 1. United States Census Bureau. Demand for Child Care and the Distribution We thank all the child care center directors who participated in this study. of Child Care Facilities in the United States: 1987–2007. Available at http:// www.census.gov/library/working-papers/2013/econ/2013_child_care.html Funding Accessed 20 May 2017. This study was supported by funding from the Nova Southeastern University 2. United States Census Bureau. Child Care an Important Part of American Health Professions Division. Grant #335548. 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Improving survey quality through pretesting. Washington, DC: U.S. Bureau of the Census; 1998. Retrieved March 5, 2018 from http://www.census.gov/srd/papers/pdf/sm98-03.pdf. 15. Dillman DA, Smyth JD, Christian LM. Mail and internet surveys: the tailored design method. 3rd ed. New York: John Wiley and Sons; 2009. 16. Lino S, Marshak HH, Herring RP, Belliard JC, Hilliard C, Campbell D, Montgomery S. Using the theory of planned behavior to explore attitudes and beliefs about dietary supplements among HIV-positive black women. Complement Ther Med. 2014;22:400–8. 17. Sigman-Grant M, Christiansen E, Fernandez G, Fletcher J, Johnson SL, Branen L, Price BA. Child care provider training and a supportive feeding environment in child care settings in 4 states, 2003. Prev Chronic Dis. 2011;8:A113. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Oral Health Springer Journals

Oral health promotion practices: a survey of Florida child care center directors

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Dentistry; Dentistry; Oral and Maxillofacial Surgery
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Abstract

Background: To understand the oral health promotion practices (OHPPs) in Florida licensed childcare centers (CCCs), we surveyed the childcare center directors (CCCDs) employed at these centers. We determined if CCC’s affiliation with Early Head Start/Head Start (EHS/HS) programs was associated with the number of OHPPs implemented. Methods: For this cross-sectional study we emailed a pretested 45-item online survey to unduplicated email addresses of 5142 licensed CCCDs as listed in the publicly available Florida Department of Child and Family services database. Univariate and bivariate analyses were conducted. In addition, a Poisson regression model predicting higher numbers of OHPPs implemented was conducted. Results: A response rate of 19.4% was estimated. CCCDs reporting to implement a higher number of OHPPs in their CCCs were more likely to have longer work experience (b = 0.006, 95% CI: 0.001,0.012 p = 0.03), work in EHS/HS affiliated centers (b = 0.7, 95%CI: 0.48,0.91) p < 0.001), and have more positive attitudes about pediatric oral health (b = 0.08, 95%CI: 0.05, 0.10) p < 0.001). CCCDs with more self-perceived barriers reported implementing a lower number of OHPPs (b = − 0.046, 95% CI: -0.09, − 0.003 p = 0.035) compared to their counterparts. Conclusions: A significant association between a CCC’s affiliation with EHS/HS programs and the number of OHPPs implemented was observed. In addition, CCCD’s years of experience, attitudes towards oral health, and self-perceived barriers in implementing OHPPs were also associated with the number of OHPPs implemented. Keywords: Oral health, Health promotion, Day care, Child care centers, Dental caries, Prevention, Head start, Early head start Background programs can be implemented in these settings to pro- The number of child care facilities in the U.S. rose from mote the health of the enrolled children. 262,511 in 1987 to 766,401 in 2007, indicating an in- One significant public health problem is an ongoing creasing trend in the establishment of such facilities [1]. epidemic of dental caries in the U.S. children. The There were 32.7 million children in ‘out-of-home’ child 2011–2012 National Health and Nutrition Examination care facilities in year 2011, of which most (20.2 million) Survey data showed that at least 40% of 2 to 8 year old were aged 5–14 years; while the remaining 12.5 million children experienced dental caries in their primary teeth, were aged 0 to 4 years [2]. Preschoolers of employed and with at least 14% having untreated tooth decay, suggest- non-employed mothers spent approximately 36 h and ing that despite needing dental care, it was not received 21 h respectively per week in these facilities [2]. Because [3]. Approximately 21% of children ages 6 to 11, and a significant proportion of children spend so much time 53% of adolescents aged 12 to 19 years had experienced in these facilities, health intervention and promotion dental caries [3]. This national data suggests that children develop dental caries all through their childhood. * Correspondence: Vinodh.Bhoopathi@temple.edu Since many children spend a portion of their day in Department of Pediatric Dentistry and Community Oral Health Sciences, CCCs, centers provide an ideal setting to adopt mea- Temple University Maurice H. Kornberg School of Dentistry, 3223 N Broad sures to prevent dental caries, especially since most Street, Philadelphia, PA 19140, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 2 of 8 children enrolled in CCCs fall into the susceptible age Institution Review Board (IRB) (Protocol number: range for dental caries. CCCs and childcare center direc- CGG2013–19). The target population for this study was tors (CCCDs) could take an active role to prevent dental CCCDs working in licensed CCCs within the State of diseases and promote oral health of all children enrolled Florida. A publicly available database comprising of un- in these centers by educating children and their parents duplicated names and email address of Florida CCCDs about the importance of maintaining proper oral health, (n = 5142) was retrieved from the Florida Department of and adopting good oral health promotion practices Children and Families website in January 2014. Eight (OHPPs) [4]. hundred and seventy seven CCCDs responded, 53 opted The American Academy of Pediatric Dentistry (AAPD) out, and 631 email addresses were invalid. The overall recognizes the importance and impact of oral health survey response rate was estimated at 19.4% (877/4511). promotion within CCCs, based on children’s increased utilization of and time spent in these facilities for daily Survey instrument care [5]. The AAPD released a set of oral health guide- The authors developed the 45-item survey by adapting lines addressing dental disease prevention and oral questions from previously tested and validated surveys health promotion in out-of-home child care settings tar- [11–13]. AAPD oral health policies for CCCs [5] were geting CCCs, pediatric dentists, other health care profes- also used to construct questions to assess OHPPs imple- sionals, legislators and policy makers [5]. This policy mented in the CCCs. A group of five pediatric dentists encourages CCCs to implement oral health promotion provided detailed feedback on the structure and content practices (OHPPs) to reduce a child’s risk of acquiring of the first draft of the survey. The second draft of the early childhood caries and the risk of dental trauma modified survey was pretested with 10 CCCDs in Bro- within their centers. ward county, Florida. The survey was pilot tested Very few studies have assessed the oral health related through cognitive interviews using the concurrent think policies and regulations in daycare or childcare centers aloud method with probes [14]. These procedures we in the U.S. [6–8]. Little is known about licensed CCCs believe improved the content and face validity of the in the state of Florida, and the type of OHPPs imple- survey. mented within these centers. Florida CCCs provide a unique opportunity to explore oral health promotion practices because children in Florida experience poorer Data collection oral health and lack adequate dental care access com- The pilot tested survey was uploaded on the Survey pared to children in many other states [9]. Therefore Monkey® online platform (www.surveymonkey.com). We our study surveyed child care center directors (CCCDs) used Dillman’s guidelines such as: 1) repeated contacts, employed in Florida licensed CCCs to determine which 2) varying messages across reminders, 3) caution to of the 8 selected AAPD recommended OHPPs were minimize spam, and 4) testing the compatibility of the already implemented, and the factors associated with a online surveys on different devices and softwares, to higher number of OHPPs implemented. Because evi- contact the CCCDs and boost the responses. [15]. For dence [10] shows that children in CCCs affiliated with repeated contact, we included: (1) an introductory email Head Start [HS] programs are significantly more likely informing the CCCDs about the upcoming survey; (2) to receive health care screenings and consultations an email with a message about the intent of the survey, compared to non-HS programs, we tested if there was why they were selected to be part of the study, and the any association between number of OHPPs imple- importance of their participation; and (3) reminder mented and the CCC’s affiliation with Early Head Start/ emails, sent every 2 weeks intervals (a total of 3 re- Head start (EHS/HS) programs. EHS/HS programs are minders), on early Monday morning hours with person- federal programs that promote school readiness among alized links, to both partial and non-respondents over a low-income children 0 to 5 years of age. These pro- 6-week period. We varied the content of the email mes- grams offer comprehensive early child hood education, sage with all reminders to vary the stimulus across email health care services, nutrition, and parental involve- contacts. To minimize the likelihood of the online sur- ment services. Many EHS/HS programs are based in vey being flagged as spam we used plain text messages, preschools, and others are located in licensed childcare instead of HTML messages. And finally, we tested the centers or family childcare homes. online survey on iphones, androids, desktops, and differ- ent software and hard ware configurations. The online Methods version of the survey was also tested for operational and Study sample typological issues. The survey was initially sent to the This cross sectional study was approved by the Nova sample in January 2014, and was kept open until the end Southeastern University Health Professions Division of March 2014. Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 3 of 8 Independent variables promotion topics; 6) Insufficient space to implement OHPPs; 7) Inadequate time to implement OHPPs; 8) In- Demographic variables Questions were asked about fection control concerns; and 9) other (open response). (but not limited to) CCCDs age, gender, race, ethnicity, All checked responses (coded as 1) were summed to- highest form of education completed, annual income, gether to derive a composite SPB score (ranging from 0 years of experience as a CCCD, and if they had a child to 9), with higher scores indicating that CCCDs had of their own. greater difficulty implementing OHPPs in their centers. Pediatric oral health knowledge (knowledge) Three Affiliation with EHS/HS programs (main independ- questions/statements assessing the CCCD’s knowledge ent variable) CCCDs were asked using a check box op- about pediatric oral health, were adapted from a previ- tion to choose if their center was affiliated with EHS/HS ous study [11]. The first statement specified that the par- programs or not. A checked response meant that CCCD ents should start cleaning a child’s mouth at the age of 1 was at a center affiliated with EHS/HS programs. (True or False response). The correct answer to this question was False, because cleaning children’s teeth Main outcome variable should begin as soon as the first tooth erupts. The sec- ond True/False statement indicated that a child’s first Oral health promotion practices (OHPPs) CCCs im- dental visit should be at 2 years. The correct answer is plementation of OHPPs, as recommended by the False because children should have a first dental office AAPD’s “Policy on Oral Health in Child Care Centers” visit at the age of 1. The third statement asked the re- [5] was measured by asking 8 binary option (yes/ no) spondents to correctly choose the most common questions. In order to accommodate the time constraints chronic childhood disease for children younger than and to prevent potential overlap between OHPPs, re- 7 years old from four possible responses (Asthma, Hay searchers developed questions for only 8 out of a pos- Fever, Tooth decay, and Chicken Pox). The correct an- sible 14 AAPD recommended OHPPs. The decision to swer for this question was tooth decay. Correct answers include only 8 of the 14 AAPD recommended OHPPs were assigned a score of 1 and were summed to create a was made based on the feedback received from 5 composite knowledge score (range 0 to 3). Higher com- pediatric dentists who provided feedback on the content posite scores indicated that CCCDs had a higher level of and structure of the survey. The questions asked the pediatric oral health knowledge. CCCDs whether the center he/she was employed at: 1) had an oral health consultant; 2) regularly maintained Attitudes towards pediatric oral health (attitudes) A dental records for enrolled children; 3) had training or 5-point Likert scale (Strongly Agree to Strongly Dis- educational programs for staff about traumatic dental in- agree; coded as 1 to 5) was used to rate the following juries 4) had an onsite dental emergency manual; 5) attitude-based statements: 1) Cleaning baby teeth is not regularly distributed oral health promotion materials to important because they fall out anyway; 2) My center parents; 6) provided optimally fluoridated water for the has too many activities to devote any time to dental children; 7) promoted the dental home concept to par- health; 3) Teaching children younger than 3 years about ents; and 8) encouraged children to brush their teeth dental health is too difficult; and 4) I don’t believe that after meals or snacks. All “yes” responses were consid- the activities that we provide in the center will prevent ered positive responses, and were given a score of 1, cavities [12]. A composite attitude score (range 0 to 20) while “no” responses were coded as 0. The responses was derived by summing the answers with higher scores were summed to derive a composite OHPS score (Score indicating positive attitudes towards promoting chil- range: 0 to 8) with higher scores indicating more OHPS dren’s oral health. An acceptable internal consistency implemented by CCCs. (Cronbach’s alpha = 0.706) was estimated for the likert scales measuring attitudes. Analyses Data analyses were performed using the version 9.3 of Self-perceived barriers (barriers) Possible barriers to the SAS statistical analysis software (SAS Institute, Inc. implementing OHPPs were listed with a check box op- Cary, N.C.). Alpha coefficients were performed to test tion. CCCDs could check any of the items that apply. reliability between items included in the attitude-based The list of barriers were: 1) Insufficient funding to pro- questions. We conducted descriptive statistics to under- mote pediatric oral health; 2) Parents’ negative attitudes stand the characteristics of the study sample. The fol- towards child safety and oral health; 3) Parental cultural/ lowing variables were described through frequencies and religious barriers; 4) Parents’ language barriers; 5) Insuf- percentages: CCCD’s age, gender, ethnicity, race, educa- ficient training of center staff about oral health tion, annual income, having a child of their own (being a Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 4 of 8 parent), and the center’s affiliation with EHS/HS pro- answered “False”. Only 2 in 5 CCCDs correctly answered grams. The following variables were described through that the child’s first dental visit should not be at 2 years. means and standard deviation: CCCD’s age, years of ex- However, an overwhelming 85% of the respondents cor- perience working at a CCC, knowledge, attitudes, bar- rectly identified that tooth decay or cavities is the most riers, and the self-reported number of OHPPs common childhood disease. implemented in their center. Bivariate comparisons were The mean attitude score (16.8 ± 2.7) suggested that conducted using chi-square tests and independent stu- CCCDs had positive attitudes towards pediatric oral dent t-tests to understand differences in the proportion health. Most of the respondents (94%) believed that of CCCDs reporting OHPPs implementation, and the cleaning baby teeth was very important. Only 9% felt overall number of OHPPs implemented in CCCs. One that that there were too many activities at the center to Poisson regression model was created which predicted devote any time to children’s dental health. Most (87%) the number of OHPPs implemented in Florida CCCs. felt that teaching children younger than 3 about the im- We included all independent variables explained above portance of oral health was not difficult. More than 65% as covariates. Multi-collinearity diagnostic analysis was believed that providing oral health promotion activities performed to assess collinearity between the predictor in CCCs will prevent dental caries. variables that were included in the regression model, CCCDs did not perceive that there were too many bar- and none was detected. To assess the fit of the poisson riers to implementing OHPPs in their centers (mean regression model, we used the goodness-of-fit SPB score: 1.55 ± 1.64). Funding issues (38.5%) and lack chi-squared test. of oral health promotion training for staff (32.7%) were the most frequently reported self-perceived barriers by Results CCCDs. Less frequent barriers were lack of time to ad- The mean age of the CCCD respondents was 48.5 ± dress oral health (24.7%), infection control issues 10.5 years and they had mean years of experience of (15.2%), lack of space to promote adequate oral health 11.6 ± 9.3 years. A majority of the study participants (14.1%), and negative parental attitudes (11.6%). Few were women (96%) and belonged to the White race CCCDs perceived parent’s language barriers (6.6%), cul- (74%). Approximately 19% of the sample was Hispanics. tural issues (5.4%), or other issues (2.5%) to be signifi- The majority (65%) reported having a college degree or cant barriers to providing OHPPs in their center. higher. More than 60% reported earning an annual in- Figure 1 illustrates the percentage of respondents come of less than $50,000, with just over 20% reporting reporting about the implementation of 8 OHPPs in their an income of $50,000 and above. Only 5% of the centers. Slightly more than half of CCCDs reported that responding CCCDs reported that their center was affili- they promote the dental home concept to parents (53%) ated with EHS/HS programs. and provide optimally fluoridated water to children On average, participants answered only one knowledge (53%), while the least implemented OHPPS were having question out of 3 correctly [Knowledge score: 1.3 ± 0.8 an oral health emergency manual on site (8%) and main- (mean ± SD)]. When asked if age 1 was the correct age taining children’s dental records (5%). On average, to initiate cleaning a child’s teeth, only 1 in 5 correctly CCCDs reported implementing only 2.1 ± 1.6 (mean ± Fig. 1 Percentage of childcare directors reporting implementation of certain oral health promotion practices in their centers Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 5 of 8 SD) out of 8 possible AAPD recommended OHPPs in Poisson regression analysis their CCCs. The adjusted Poisson regression model predicting higher number of OHPPs implemented in Florida licensed CCCs is showninTable 2. CCCDs employed at a center affiliated Bivariate analysis with EHS/HS programs reported implementing a higher Tables 1 compares the differences in number of OHPPs number of OHPPs compared to CCCDs at centers not affil- implemented by selected characteristics of CCCDs. No iated with EHS/HS programs (b = 0.7, 95%CI: 0.48,0.91) p significant differences in OHPPs implemented were ob- < 0.001). The results also confirmed that CCCDs reporting served by ethnicity, income, and having a child of their higher number of OHPPs implemented in their centers own. Male CCCDs reported a significantly higher num- were more likelytohavelongerworkexperience(b=0.006, ber of OHPPs implemented compared to female CCCDs 95% CI:0.001, 0.012 p = 0.03), and have more positive atti- (p= 0.02). Those belonging to a non-White racial back- tudes about pediatric oral health (b = 0.08, 95%CI: 0.05, ground (p= 0.001), and those with a college degree (p 0.10) p < 0.001). CCCDs who had more self-perceived bar- = 0.03) and above reported implementing a significantly riers in implementing OHPPs reported that their centers higher number of OHPPs compared to their counter- had implemented significantly lower number of OHPPs (b parts. Table 2 compares CCCs affiliated with EHS/HS = − 0.046, 95% CI: -0.09, − 0.003 p = 0.035). The goodness programs to unaffiliated centers. More EHS/HS affiliated of fittestprovedthatthe Poissonregressionmodel fitthe CCCDs consistently reported implementing 7 OHPPs data reasonably well because the test was not statistically compared to their counterparts, with the exception of significant (p = 0.094). one OHPP. Directors in EHS/HS affiliated centers were as likely (52%) to report providing clean optimally fluori- Discussion dated water throughout the day as directors in centers Understanding the oral health promotion practices in that are not affiliated (47%). Overall, the directors in Florida licensed CCCs is important because these cen- centers affiliated with EHS/HS programs reported to ters can be utilized as alternate non-traditional settings have implemented a significantly higher mean number to promote optimal oral health of children. So we con- (5.1 ± 2.3) of OHPPs compared to those in centers not ducted a survey of CCCDs in Florida licensed CCCs to affiliated (1.9 ± 1.8). examine whether their center implemented any OHPPs, and if their center’s affiliation with EHS/HS programs af- fected the number of OHPPs implemented. Of the 8 OHPPs assessed, our findings indicate that, Table 1 Mean differences in OHPPs implemented by selected on average, CCCDs reported implementing very few CCCD characteristics OHPPs in their centers, suggesting that OHPPs may not Variable OHPPs (mean ± SD) p-value adequately practiced in these centers. More than 80% of Gender the CCCDs reported that their enrollees did not brush Male 2.79 ± 2.2 0.02 after meals, their center lacked an oral health consultant and oral health emergency manuals, the staff were not Female 2.04 ± 1.6 trained in traumatic dental injuries, and did not main- Race tain children’s dental records. This indicates that, based White 1.95 ± 1.5 0.001 on the CCCDs’ reports, AAPD recommended oral health Non-White 2.39 ± 1.9 prevention and promotion activities were not frequently Ethnicity practiced in licensed Florida CCCs. In fact, a substantial Hispanics 2.24 ± 1.7 0.15 number of children younger than 5 years old were en- rolled in these centers at the time of our study (more Non-Hispanics 2.02 ± 1.6 than 80%), which is problematic because this age group Income has high dental caries risk and oral health promotion > =50,000 2.04 ± 1.5 0.92 should already be initiated. At least in this study, we did < 50,000 2.03 ± 1.6 not find any association between CCCD’s oral health Education knowledge and the number of OHPPs implemented. College degree and above 2.16 ± 1.7 0.03 However, possessing correct oral health knowledge and high oral health literacy is important for CCCDs to prac- < College degree 1.89 ± 1.4 tice appropriate OHPPs not only for themselves but also Have Child Of your own to implement into that childcare system that will benefit Yes 2.04 ± 1.6 0.9 the enrolled children. Therefore Florida CCCDs need No 2.06 ± 1.7 more education about the importance of implementing Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 6 of 8 Table 2 Factors predicting higher number of oral health promotion practices implemented in Florida child care centers Variable Paramester 95% CI p-value estimate Age 0.006 (−0.001, 0.013) 0.95 Years of experience (Higher number) 0.006 (0.0006, 0.012) 0.03 Gender (Male versus Female) 0.093 (−0.224, 0.41) 0.57 Race (White versus Non-Whites) −0.08 (−0.218, 0.057) 0.25 Have a Child of your own (Yes Versus No) 0.074 (−0.073, 0.22) 0.33 Income (< 50,000 versus > = 50,000) −0.009 (−0.15, 0.132) 0.90 Education (college degree and above versus Less than college degree) 0.033 (−0.103, 0.17) 0.64 Type of Center (Early Head Start Versus Non-Early Head Start) 0.7 (0.48, 0.914) <.0001 Oral Health Knowledge (Higher number) 0.001 (−0.08, 0.08) 0.98 Attitudes (Higher number) 0.08 (0.05, 0.103) <.0001 Barriers (Higher number) −0.046 (− 0.09, − 0.003) 0.035 OHPPs within their CCCs, along with the long-term im- insufficient staff time for pediatric oral health promo- pact it can have on a child’s overall health and tion. Previous literature has shown that these three ele- well-being. However, it was encouraging to find that ments are critical to the success of any health promotion most participants (67%) reported that they might imple- or disease prevention programs in CCCs. Therefore we ment OHPPs in the upcoming year. recommend that CCCDs identify strategies to overcome To test our hypothesis and to determine factors asso- these three barriers to health promotion. Additional ciated with more implemented OHPPs in Florida CCCs, open-ended responses provided insights into other po- we conducted an adjusted Poisson regression model that tential barriers faced by CCCDs when implementing yielded interesting results. Our study found that CCCDs OHPPs including: dentists rarely treating and educating working in EHS/HS affiliated centers implemented more children younger than 3 years, few community dentists, OHPPs compared to their counterparts (p < 0.001). We and there is no need to enforce oral health promotion at conclude that there was a significant association between the center because it is not required for Florida’s the number of OHPPs implemented and the center’s af- licensure. filiation with EHS/HS programs. Literature supporting Ours is the first study to survey CCCDs in Florida on this result exists, with HS centers promoting health con- relevant OHPPs in their centers. Therefore our study siderably more frequently than non-HS centers [10]. In a highlights for the first time, the status of licensed CCCs multi-state survey a higher proportion of responding in Florida and the lack of adequate oral health promo- CCCDs in HS centers reported consulting health profes- tion in these settings. Limitations of this study include sionals and screening for health problems in enrolled but are not limited to low response rate, use of a con- children, compared to their counterparts. This is due to venience sample, and induced bias due to selective par- greater awareness about pediatric health, and CCCDs in ticipation. Therefore our study results should be HS centers may attach greater importance to children’s interpreted with caution. Only 5% of the respondents re- health issues [10]. More experienced CCCDs may have ported working in EHS/HS affiliated centers compared been more confident and efficacious compared to inex- to their counterparts (95%). A previous study showed perienced CCCDs, and therefore may have implemented very similar findings, with only 10% of the responding more OHPPs. CCCDs with positive pediatric oral health CCCDs reporting to work at HS affiliated centers [10]. promotion attitudes were more likely to report imple- We did not find information about the proportion of li- menting OHPPs in their centers. Evidence suggests that censed CCCs in Florida that were affiliated with EHS/ those with more positive attitudes about health mainten- HS programs and therefore we were unable to determine ance are more likely to adopt and practice healthy be- if non-EHS/HS CCCDs were more or less likely to par- haviors for their own well-being [16]. Prior research ticipate in the survey compared to their counterparts. A supports the idea that more barriers (perceived and real) very small proportion of the respondents were males. impede prevention program implementation [17]. The Other types of childcare facilities, such as non-licensed most frequently reported barriers to implementing CCCs, group childcare homes or family child care OHPPs by study participants were: 1) insufficient fund- homes, were not explored because we did not have ac- ing to implement oral health programs, 2) insufficient cess to these facilities. Understanding the demographic staff training about oral health promotion, and 3) differences between respondents and non-respondents Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 7 of 8 could not be accomplished because the researchers did manuscript. RJ: Study design, data analysis, and critical editing of the manuscript for important intellectual content. All authors read and approved not manually track the participants as deemed by the the final manuscript. IRB guidelines. Due to the limited funds to execute this study, postal surveys were not economically feasible. Authors’ information Dr. Vinodh Bhoopathi, was an Assistant Professor at Nova Southeastern Because the EHS/HS affiliated centers implement University College of Dental Medicine, and the thesis committee chair for Dr. more OHPPs, we believe that EHS/HS programs may Joshi’s thesis when this study was conducted. Currently Dr. Bhoopathi is an serve as a model that can be integrated into non-EHS/ Assistant Professor at the Temple University Maurice H Kornberg School of Dentistry, Philadelphia, PA. Dr. Ajay Joshi was a pediatric dental resident at HS affiliated programs. Because many children receive Nova Southeastern University College of Dental Medicine when this thesis daycare in CCCs, it is imperative that policy makers and study was conducted. Currently he is an Assistant Clinical Professor at State Departments of Health focus on policies and regu- Indiana University School of Dentistry and maintains his private practice in Marion, IN. Dr. Romer Ocanto is Associate Professor, and Chair of Pediatric lations that will improve the integration of OHPPs into Dentistry at Nova Southeastern University. Dr. Robin J. Jacobs is Associate these settings. For example, in the State of Florida, the Professor at Nova Southeastern University College of Osteopathic Medicine child care licensing program is a component of the ser- at the time of the study. Currently she is an Associate Professor at Baylor College of Medicine. Address correspondence to Dr. Bhoopathi. E-mail: vices provided by the Department of Children and Fam- Vinodh.Bhoopathi@temple.edu ilies. This program through regulations and consultation ensures that licensing requirements are met by the Ethics approval and consent to participate childcare facilities thus preventing operation of sub- This study was approved by the Institution review board (IRB) at the Nova Southeastern University Health Professions Division (Protocol: CGG2013–19). standard childcare programs. Such departments can add Participants were informed through an email message about the objectives mandatory regulations related to maintaining certain of the study and that by clicking the online survey link they were consenting oral health standards in CCCs. By doing so, optimal oral to participate in the study. They were also informed that their participation is voluntary and anonymous, and that they may choose anytime to not health in children can be achieved by all CCCs. Child participate in the study. care centers are non-traditional alternate settings where new disease prevention and health promotion programs Competing interests Dr. Bhoopathi is an Associate Editor of the BMC Oral Health Editorial Board. can be implemented to improve the health of enrolled Other author(s) declare no competing interests. children. These settings are excellent resources to apply oral health intervention programs, provided there are Publisher’sNote few barriers. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Conclusions Author details We conclude that affiliation with EHS/HS programs is Department of Pediatric Dentistry and Community Oral Health Sciences, associated with the number of OHPPs implemented li- Temple University Maurice H. Kornberg School of Dentistry, 3223 N Broad censed Florida licensed CCCs. In addition, CCCDs years Street, Philadelphia, PA 19140, USA. Pediatric Dentistry Department, Indiana University School of Dentistry, 1121 W. Michigan Street, Indianapolis, IN of experience, attitudes towards oral health, and 46202, USA. Department of Pediatric Dentistry, Nova Southeastern University self-perceived barriers in implementing OHPPs were College of Dental Medicine, 3200 S University Drive, Fort Lauderdale, FL also associated with number of OHPPs implemented. 33328, USA. Department of Family and Community Medicine – Research Programs, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston, Abbreviations TX 77098, USA. AAPD: American Academy of Pediatric Dentistry; CCCDs: Child care center directors; CCCs: Child care centers; EHS/HS: Early Head Start/ Head Start; Received: 25 October 2017 Accepted: 22 May 2018 HS: Head Start; IRB: Institution Review Board; OHPPs: Oral health promotion practices References Acknowledgements 1. United States Census Bureau. Demand for Child Care and the Distribution We thank all the child care center directors who participated in this study. of Child Care Facilities in the United States: 1987–2007. Available at http:// www.census.gov/library/working-papers/2013/econ/2013_child_care.html Funding Accessed 20 May 2017. This study was supported by funding from the Nova Southeastern University 2. United States Census Bureau. Child Care an Important Part of American Health Professions Division. Grant #335548. The funding agency did not Life. How do we know? Available at: https://www.census.gov/content/ contribute to the design of the study, collection, analysis, and interpretation dam/Census/library/visualizations/2013/comm/child_care.pdf . Accessed of data, and in writing the manuscript. 17 Apr 2017. 3. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant Availability of data and materials prevalence in children and adolescents in the United States, 2011–2012. Data cannot be shared at this time because more publications are planned NCHS data brief, no 191. Hyattsville: National Center for Health using the same data. Statistics; 2015. 4. Kim J, Kaste LM. Associations of the type of childcare with reported Authors’ contributions preventive medical and dental care utilization for 1- to 5-year-old children VB: Conceptualization, study design, data collection and analysis, writing in the United States. Community Dent Oral Epidemiol. 2013;41:432–40. manuscript, critical editing of the manuscript for important intellectual 5. Policy on Oral Health in Child Care Centers. Pediatr Dent. 2012;34:33–4. content. AJ: Data collection, manuscript writing, critical editing of the 6. Kranz AM, Rozier RG. Oral health content of early education and child care manuscript. RO: Study design, manuscript writing, critical editing of the regulations and standards. J Public Health Dent. 2011;71:81–90. Bhoopathi et al. BMC Oral Health (2018) 18:96 Page 8 of 8 7. Kim J, Kaste LM, Fadavi S, et al. Are state child care regulations meeting national oral health and nutritional standards? Pediatr Dent. 2012;34:317–24. 8. Scheunemann D, Schwab M, Margaritis V. Oral health practices of state and non-state-funded licensed childcare centers in Wisconsin, USA. J Int Soc Prev Community Dent. 2015;5:296–301. 9. The Pew Center of States. 2011. The State of Children’s Dental Health: Making Coverage Matter. The Pew Charitable Trusts. Available at http:// www.pewtrusts.org/~/media/legacy/uploadedfiles/wwwpewtrustsorg/ reports/state_policy/childrensdental50statereport2011pdf.pdf . 10. Gupta RS, Pascoe JM, Blanchard TC, Langkamp D, Duncan PM, Gorski PA, Southward LH. Child health in child care: a multi-state survey of head start and non-head start child care directors. J Pediatr Health Care. 2009;23:143–9. 11. Akpabio A, Klausner CP, Inglehart MR. Mothers’/guardians’ knowledge about promoting children’s oral health. J Dent Hyg. 2008;82:12. 12. Mathu-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;68:154–62. 13. Joshi A, Ocanto R, Jacobs RJ, Bhoopathi V. Florida child care center directors’ intention to implement oral health promotion practices in licensed child care centers. BMC Oral Health. 2016;16(1):100. 14. DeMaio TL, Rothgeb J, Hess J. Improving survey quality through pretesting. Washington, DC: U.S. Bureau of the Census; 1998. Retrieved March 5, 2018 from http://www.census.gov/srd/papers/pdf/sm98-03.pdf. 15. Dillman DA, Smyth JD, Christian LM. Mail and internet surveys: the tailored design method. 3rd ed. New York: John Wiley and Sons; 2009. 16. Lino S, Marshak HH, Herring RP, Belliard JC, Hilliard C, Campbell D, Montgomery S. Using the theory of planned behavior to explore attitudes and beliefs about dietary supplements among HIV-positive black women. Complement Ther Med. 2014;22:400–8. 17. Sigman-Grant M, Christiansen E, Fernandez G, Fletcher J, Johnson SL, Branen L, Price BA. Child care provider training and a supportive feeding environment in child care settings in 4 states, 2003. Prev Chronic Dis. 2011;8:A113.

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BMC Oral HealthSpringer Journals

Published: Jun 1, 2018

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