|Year : 2018 | Volume
| Issue : 1 | Page : 86-92
Integration of oral health in primary health care through motivational interviewing for mothers of young children: A pilot study
Manu Batra1, Aasim Farooq Shah2, Jorma I Virtanen3
1 Department of Public Health Dentistry, Surendera Dental College and Research Institute, Sri Ganganagar, Rajasthan, India
2 Department of Public Health Dentistry, Government Dental College and Hospital, Srinagar, Jammu and Kashmir, India
3 Research Unit of Oral Health Sciences, Faculty of Medicine, University of Oulu and Medical Research Center, Oulu University Hospital, Oulu, Finland
|Date of Web Publication||28-Mar-2018|
Dr. Manu Batra
Department of Public Health Dentistry, Surendera Dental College and Research Institute, Sri Ganganagar, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Early childhood caries (ECC) continues to affect children worldwide. In India, primary health centers (PHCs) comprises the primary tier where Accredited Social Health Activist (ASHA) provide integrated curative and preventive health care. The aim of the study was to pilot test the integration of oral health in primary health care through motivational interviewing (MI) for mothers of young children provided by ASHAs. Subjects and Methods: The pilot study was conducted in Kashipur, Uttarakhand. From the six PHCs in Kashipur, three were randomly selected, one each was assigned to MI group, traditional health education group, and control group. From 60 mothers with 8–12 months child, ASHAs of all three groups gathered mother's knowledge regarding child's oral health using close-ended questionnaire and diagnosed clinical risk markers of ECC in children and ASHAs of Group A and B imparted the oral health education as per their training. Results: The comparison of ASHA's performances on the MI training competency pre- and post-test showed an overall average of 74% improvement in post–test scores. Interexaminer reliability of the parallel clinical measurements by 6 ASHAs and the investigator for the maxillary central incisors showed 93% of agreement for both dental plaque and dental caries assessment with 0.86 and 0.89 kappa values, respectively. Conclusion: The health education through MI is feasible and can be cost-effective by utilization of ASHAs at PHCs to provide the oral health education to mothers which will in turn improve the oral health status of children.
Keywords: Accredited Social Health Activists, early childhood caries, mothers, motivational interviewing
|How to cite this article:|
Batra M, Shah AF, Virtanen JI. Integration of oral health in primary health care through motivational interviewing for mothers of young children: A pilot study. J Indian Soc Pedod Prev Dent 2018;36:86-92
|How to cite this URL:|
Batra M, Shah AF, Virtanen JI. Integration of oral health in primary health care through motivational interviewing for mothers of young children: A pilot study. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2019 Nov 22];36:86-92. Available from: http://www.jisppd.com/text.asp?2018/36/1/86/228741
| Introduction|| |
Early childhood caries (ECC) is a public health problem that continues to affect babies, preschool children, and toddlers worldwide. In India, a prevalence of 44% has been reported for caries in 8–48-month-old children. Professional dental services are scarce and thus considered irrelevant for the prevention of ECC in the fast growing population with a birth rate of 1.2%. Although assimilating oral disease prevention into broader health promotion seems to be an efficient way  still such integration is missing in developing and developed countries. The recommended approach is educating the parents about the importance of oral hygiene and healthy diet in avoiding ECC.
In India, a majority of the population resides in rural areas. Their healthcare is organized as a three-tier structure based on size of population covered. Primary health centers (PHCs) along with the sub centers comprise the primary tier and provide integrated curative and preventive healthcare to the rural population with emphasis on preventive and promotive aspects. Community health center forming the uppermost tier is established and maintained by the State Government, but the PHCs along with the subcenter are the primary source of availing the health services in rural areas. At each PHC, two or more Accredited Social Health Activists (ASHA) belongs to the staff. Among other things, their duties cover vaccinations and general health-related education for families with young children. Empowered with knowledge and a drug-kit to deliver first-contact healthcare, every ASHA is expected to be a fountainhead of community participation in public health programs in her village.
Overall, the ratio of dentists to population in India is 1:19,000 whereas in rural India, one dentist is serving over 200,000 of people. To counter the above-stated problem, the role of the ASHAs could be expanded to include the oral health-related aspects in their duties and thus improve dental awareness and health in rural areas.
Traditional health education seems to be insufficient in changing parents' behavior, as parents do not go to health professionals in a state of readiness to change patterns of behavior those are well established. An alternative innovative method which can be used in passing on the dental health education to the caregivers is motivational interviewing (MI) as it is more focused and goal directed. MI is a directive, client-centerd counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. It is more focused and goal-directed compared with non-directive counseling.
In tackling the ECC in rural areas of India, the study was designed for imparting oral health-related awareness at the grass root level. Consequently, ASHAs were trained to deliver the oral health-related education to the mothers with young children using either the traditional, i.e., providing oral health education through verbal communication or the MI method. In addition, we trained the ASHAs to observe the risk markers of poor oral hygiene as well as the first signs of ECC in young children.
The current pilot study tested the design and practical implementation of the planned interventional study among mothers with 8–12-month-old children visiting the PHCs in Kashipur city, Udham Singh Nagar district Uttarakhand, India. The objectives of the pilot study included (a) testing the integration of oral health-related aspects to the general health education at the PHCs, (b) testing the feasibility and competency of MI in providing oral health education to mothers of 8–12 months and (c) testing the feasibility of ASHAs in diagnosing clinical risk markers of poor oral hygiene and dental caries. The findings of this piloting will aid in appropriate sample size needed for illustrating outcomes of the interventions.
| Subjects and Methods|| |
A randomized, single-blind interventional pilot study was conducted in Kashipur city of Udham Singh Nagar district, Uttarakhand, India, during May to July 2014. The permission was granted by the chief medical officer of the district. At the PHCs, child vaccination is a regular program with a determined schedule. Sixty mothers with an 8–12-month-old child visiting the PHC at Kashipur were enrolled in the present pilot study.
The selection of PHCs and mother-child pairs – the district has 25 PHCs out of which 6 are in Kashipur block. On the day of vaccination, on an average 25–30 mother-child pairs of required age group visited each PHC. From the six PHCs in Kashipur, three were randomly selected. From the mothers visiting the PHC with 8–12-month-old child at the vaccination day, the 20 first coming ones in each PHC were invited to participate and were enrolled in study after verbal consent. In case the child was with serious poor health condition, the next mother was selected. The sample size of sixty mother-child pairs (20 in each group) was calculated by keeping standardized difference as small and assuming power of main trial to be 80% under noncentral t-distribution approach for sample size estimation.
Overall description of the study
Among the three selected PHCs, one each was assigned to the two interventional groups and one control group: Group A (motivational intervention), Group B (traditional health education), and Group C (control). First of all, a day before of piloting, two ASHAs each from Group A and Group B underwent respective training, i.e., Group A - traditional health education + MI and Group B - traditional health education; provided by the investigator (MB). After those ASHAs acceptability of integrating oral health with general health was assessed by recording their opinions with open feedback forms. Next step was training of ASHAs of all three groups for mother's interview using a close-ended questionnaire about mother's knowledge regarding child's oral health and diagnosing clinical risk markers of ECC in children.
On day of piloting ASHAs conducted interviews with mothers of 8–12 months old child visiting the respective PHCs. ASHAs of Group A and B imparted the oral health education as per their training. After that clinical assessment of the child which included assessment of dental plaque and dental caries was done by the ASHAs.
Training of Accredited Social Health Activists
Oral health education and motivational interviewing training
The investigator (MB) formulated an oral health education booklet for the ASHAs comprising the basic oral health education needed for target population. The manual was reviewed by experts in dental public health. All components were viewed as being consistent with the theory of behavior change underlying MI. Additional feedback was requested from the ASHAs.
ASHAs of Group A and B were given 2 h educational training as per the group. It was conducted by the investigator (MB) a day before of vaccination with help of an oral health education booklet compiled, especially for the study in local language which had following key points – importance of teeth, anatomy of teeth, eruption pattern, common dental problems in early childhood, and its prevention. In Group A, ASHAs were also briefed up about the MI technique by the investigator. As rapport is established with the mother, they were instructed to ask open-ended questions, listen carefully and encourage the patient to talk, thereby identifying a discrepancy between present behaviors and important goals (in this case, the dental health of the child). MI counselors avoid giving premature advice – advice provided before a relationship has been formed or before the recipient gives the counselor permission to provide advice. The competency test for ASHAs was adapted from a previously formulated test. The test included 7 questions related to principles consistent with an MI approach.
After the training session an open-ended feedback forms regarding ASHAs acceptability rate in proving oral health along the general health education to mothers and express their views on incorporating oral health along with general health was filled by ASHAs. The feedback forms was assessed by investigator for testing the possibility of integrating oral health-related aspects to the general health education and the utilization of ASHAs as informants of oral health-related behaviors using MI method for Group A ASHAs. All the responses were dichotomized, i.e., accepted or rejected by the specialists.
Training of Accredited Social Health Activists for diagnosing clinical risk markers of early childhood caries
The training for clinical assessment was provided to ASHAs of all three groups. The clinical assessment of child for diagnosing clinical risk markers of ECC was first shown to ASHAs on a power point presentation, and then a demonstration on a child was given by the investigator.
Ten children of 8–12 months having either dental plaque or dental caries or both were selected by the investigator on the day of training and all ASHAs made to assess dental plaque or dental caries were after the training provided by the investigator to ASHAs. All 10 children were assessed by investigator and 6 ASHAs for dental plaque and dental caries, keeping their scores confidential. After the completion of assessment the assessment sheets of all 6 ASHAs were assessed for performing interexaminer reliability Kappa statistics keeping investigator as gold standard. The Kappa result be interpreted as follows: Values ≤0 as indicating no agreement and 0.01–0.20 as none to slight, 0.21–0.40 as fair, 0.41–0.60 as moderate, 0.61–0.80 as strong, and 0.81–1.00 as almost perfect agreement.
Questionnaire for mother's interview
The questions covered sociodemographic data as the age of the mother in years, and of the child in months, as mother's and father's education attained (no schooling; primary, middle, high school; intermediate, and graduate level), and as income and size of the family. The questions about the child included gender, birth term and order, and number of siblings. Further questions were about dietary habits, such as breastfeeding, use of milk and sugary drink bottle and daily eating. The questions about mother's practices related to the child's oral health included-the frequency of and equipment for tooth cleaning and visit to a dentist. Mother's own tooth brushing and visiting a dentist was asked as well. Mother's oral health-related knowledge was measured by modified questionnaire , having ten statements each to be answered using five options from strongly agree to strongly disagree. All questions, except for mother's and child's age, were close ended.
Clinical assessment of child
Recordings included number of all teeth separately in maxilla and mandible, and presence of dental plaque and dental caries on the central maxillary incisors only. The child was examined in a knee-knee position. The head of the child was placed on the examiner's lap and legs on mother's lap. During examination mother were holding the legs and arms of the children, so the examination is carried out without any interference. Type III clinical examination  (include use of mouth mirror and probe and examination in the natural daylight) was conducted under natural light. Dental plaque was inspected on the labial surface of the tooth and recorded as no plaque, plaque present at gingival margin only, or abundant dental plaque covering more than gingival margin only. The criteria for caries diagnosis were according to the WHO recommendations. Decayed teeth (dt) included the teeth with visually diagnosed cavitated lesions. If doubt existed, the surface was investigated with a WHO probe. When the ball tip of the probe failed to enter the lesion, the tooth was recorded as sound (non-carious. To test the feasibility of ASHAs as informants of oral health-related behaviors and in diagnosing clinical risk markers of poor oral hygiene and dental caries, measurement of agreement-kappa statistics was performed for both dental plaque as well as dental caries assessment.
Supervision of implementation
Supervision of the implementation was done by investigator and 02 public health dentists who were briefed about the research. Three-fold supervision was done – (a) Filling up of the questionnaire; (b) ASHA imparting the oral health education-both traditional as well as MI; and (c) Clinical assessment of child. The ASHAs were told to note down their problems faced during the session and later on the principal investigator resolved those issues. Assessment of plaque was the highlighted problem by the nurses, which was tried to eliminate by redemonstrating the plaque assessment procedure.
Descriptive statistics was performed using SPSS version 20.0 (IBM Corp., Armonk, NY, USA) statistical software. Interexaminer reliability was assessed using Kappa statistics.
| Results|| |
The profile of the mothers and child who participated in the pilot study is illustrated in [Table 1]. Mean age of the mothers was 27.4 ± 2.51 years. For 46% of mothers, intermediate was the highest education level. About 50% of mothers reported to solely breastfeed their children till 6–9 months. The mean age of infants was reported to be 11.7 ± 1.83 months. Child's teeth cleaning frequency among the majority of mothers was once in a day [Table 1].
|Table 1: Descriptive profile of mothers and children piloted in the study|
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Frequency crosses tabulation for measurement of agreement among investigator and 6 ASHAs in dental plaque assessment and dental caries assessment showed no skewness. Inter examiner reliability of the parallel clinical measurements by six examiners (ASHAs) and the investigator for the upper central incisors of ten children showed 93% of agreement for both dental plaque and dental caries assessment with 0.86 and 0.89 kappa values, respectively [Table 2].
|Table 2: Inter examiner reliability of the parallel clinical measurements by six examiners (Accredited Social Health Activists) and the investigator for the upper central incisors of ten children aged 8-12 months|
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On analysis of the responses of the ASHAs, 100% acceptability rate was found. There was a unanimous positive feedback for incorporating oral health with general health education provided by ASHAs. The comparison of ASHA's performances on the MI training competency pre and post test showed an overall average of 74% improvement in post test scores as compared to pre test scores.
The clinical examination revealed that 65% of the infant were having dental plaque on gingival margins or more on the tooth surfaces. About 19% of infants piloted were having dental caries on both or either of maxillary central incisors [Table 3].
The data related to mother's knowledge related to infant's oral health shows that 100% of mothers agreed that there is nothing wrong with putting the baby to bed with a bottle. Majority of mothers had a neutral response regarding the need of early dental checkups for infant oral health. All the mothers agreed that eating sweet food does cause tooth decay. None of mothers agreed that decayed primary teeth should be restored as soon as possible. None of them knew that dental caries is initiated by dental plaque. About 100% of mothers agreed that cavities in baby teeth do not matter since they fall out anyway. 53.3% of mothers were not sure that they can do anything to stop their child from developing dental cavities. 63.3% of mothers disagreed that children don't need to brush every day until they get their permanent teeth [Table 4].
| Discussion|| |
The study was conducted to pilot test the design and practical implementation of the MI technique for providing oral health education through ASHAs among mothers with 8–12-month-old children visiting the PHCs.
The proposed technique was expected to have the potential to reduce ECC in young children of Indian population by utilizing the available workforce at PHC. The delivery of intervention was planned through ASHAs because of poor dentist: Population ratio in India and also lack of other materialistic resources.
The encouraging finding of the success of educational intervention in caries prevention of some previous studies on oral health education and dietary counseling for mothers of very young children provided the base of this study., Early childhood is a critical stage for forming health habits, and parents are often receptive at this stage, this period offers a unique opportunity for behavioral interventions. Traditionally, health education focuses on disseminating information and giving normative advice. The insufficiency of traditional health education has been documented. Although dental knowledge can almost always be improved by traditional, such knowledge gain does not translate into sustained changes in dental behaviors. To address the limitations of CE, MI was developed as an interventional style. Evolving from Rogers' person-centered counseling approach and embracing the trans-theoretical theory, MI elicits clients' intrinsic motivations, enhances their readiness to change, and helps to explore and resolve ambivalence.
Appropriate training and encouragement for ASHAs working in primary care have proved effective in providing oral health promotion and disease prevention activities. A report by shows the best cost-benefit ratio for an oral health education program, in comparison to several other preventive programmes, including water fluoridation, fissure sealant therapy, and slow-release fluoride device. A study conducted by Nair et al. has reported that utilizing community health workers to impart oral health education to mothers was highly beneficial. Raj et al. have reported that there was significant improvement in oral health of preschool children after their mothers received oral health education from trained Anganwadi workers. In a developing country like India where financing any sort of preventive program becomes a bit difficult. Hence, in such a situation, integrating oral health education program as a routine service to the duties of already existing staffs and not recruiting any new staff can be beneficial.
Using an intervention manual developed by review of expert group, ASHA was trained to implement MI under Group A of the study. The ASHA had no initial exposure to MI, but after the training, there was a unanimous positive feedback with 100% acceptability. After individual training, ASHA-and instructor-rated competence with MI improved from novice to skilled. Another striking point was that no attrition was observed because the ASHAs had a close contact with mothers as it was part of their routine work. All the mothers completed the sessions and also attended the reminder calls made by the ASHAs which were confirmed by the investigator by calling the mothers after 2 months. Although 0% attrition over 2 months time period is unusual for psychosocial interventions. Although the time period of follow-up was small, it can be considered an adequate dose of the intervention because even brief MI is efficacious. The efficiency of MI has been demonstrated by a previously study conducted on randomized immigrant parents of 240 infants (ages 6–18 months) to either traditional health education or MI for ECC prevention and found that, after 1 year, children in the MI group had significantly fewer carious lesions than the traditional dental education group. Another exploratory controlled study conducted in Trinidad showed that using an MI approach when delivering oral health information had a positive effect on parent/caregiver of preschool children's oral health knowledge, attitudes, and behaviors when compared to traditional dental health education.
The findings of the current pilot study show that in India, the child's oral health is a neglected domain and the knowledge, attitude, and practices among the mothers toward child's oral health are unsatisfactory. The current study illustrates that the health education through MI is feasible and can be effective in improving the scenario. The utilization of ASHAs at PHCs was found to be a feasible and could be cost-effective method to provide the oral health education to mothers which will in turn improve the oral health status of children. There is a further need of a follow-up research dedicated to assess the effectiveness of utilizing the ASHAs in providing the oral health education through MI technique to the mothers of infants. The current pilot study can lay as foundation for a comprehensive large-scale parent MI program for dental care of children.
We would like to express our gratitude to our overseer Dr. Miira M Vehkalahti From Institute of Dentistry, University of Helsinki, Helsinki, Finland, for providing us the opportunity to take on this research topic under her able guidance. She has immensely helped us with the useful comments, remarks, and engagement through the preparation of the protocol for the study and manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]