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1.  Design of a community-based intergenerational oral health study: “Baby Smiles” 
BMC Oral Health  2013;13:38.
Background
Rural, low-income pregnant women and their children are at high risk for poor oral health and have low utilization rates of dental care. The Baby Smiles study was designed to increase low-income pregnant women’s utilization of dental care, increase young children’s dental care utilization, and improve home oral health care practices.
Methods/design
Baby Smiles was a five-year, four-site randomized intervention trial with a 2 × 2 factorial design. Four hundred participants were randomly assigned to one of four treatment arms in which they received either brief Motivational Interviewing (MI) or health education (HE) delivered during pregnancy and after the baby was born. In the prenatal study phase, the interventions were designed to encourage dental utilization during pregnancy. After childbirth, the focus was to utilize dental care for the infant by age one. The two primary outcome measures were dental utilization during pregnancy or up to two months postpartum for the mother, and preventive dental utilization by 18 months of age for the child. Medicaid claims data will be used to assess the primary outcomes. Questionnaires were administered at enrollment and 3, 9 and 18 months postpartum (study end) to assess mediating and moderating factors.
Discussion
This trial can help define the most effective way to provide one-on-one counseling to pregnant women and new mothers regarding visits to the dentist during pregnancy and after the child is born. It supports previous work demonstrating the potential of reducing mother-to-child transmission of Streptococcus mutans and the initiation of dental caries prevention in early childhood.
Trial registration
ClinicalTrials.gov Identifier NCT01120041
doi:10.1186/1472-6831-13-38
PMCID: PMC3751087  PMID: 23914908
Counseling; Motivation; Dental caries; Early childhood caries; Health Education; Dental; Mothers; Infant
2.  Treatment fidelity of brief motivational interviewing and health education in a randomized clinical trial to promote dental attendance of low-income mothers and children: Community-Based Intergenerational Oral Health Study “Baby Smiles” 
BMC Oral Health  2014;14:15.
Background
Fidelity assessments are integral to intervention research but few published trials report these processes in detail. We included plans for fidelity monitoring in the design of a community-based intervention trial.
Methods
The study design was a randomized clinical trial of an intervention provided to low-income women to increase utilization of dental care during pregnancy (mother) or the postpartum (child) period. Group assignment followed a 2 × 2 factorial design in which participants were randomly assigned to receive either brief Motivational Interviewing (MI) or Health Education (HE) during pregnancy (prenatal) and then randomly reassigned to one of these groups for the postpartum intervention. The study setting was four county health departments in rural Oregon State, USA. Counseling was standardized using a step-by-step manual. Counselors were trained to criteria prior to delivering the intervention and fidelity monitoring continued throughout the implementation period based on audio recordings of counselor-participant sessions. The Yale Adherence and Competence Scale (YACS), modified for this study, was used to code the audio recordings of the counselors’ delivery of both the MI and HE interventions. Using Interclass Correlation Coefficients totaling the occurrences of specific MI counseling behaviors, ICC for prenatal was .93, for postpartum the ICC was .75. Participants provided a second source of fidelity data. As a second source of fidelity data, the participants completed the Feedback Questionnaire that included ratings of their satisfaction with the counselors at the completion of the prenatal and post-partum interventions.
Results
Coding indicated counselor adherence to MI protocol and variation among counselors in the use of MI skills in the MI condition. Almost no MI behaviors were found in the HE condition. Differences in the length of time to deliver intervention were found; as expected, the HE intervention took less time. There were no differences between the overall participants’ satisfaction ratings of the HE and MI sessions by individual counselor or overall (p > .05).
Conclusions
Trial design, protocol specification, training, and continuous supervision led to a high degree of treatment fidelity for the counseling interventions in this randomized clinical trial and will increase confidence in the interpretation of the trial findings.
Trial registration
ClinicalTrials.gov: NCT01120041
doi:10.1186/1472-6831-14-15
PMCID: PMC3996055  PMID: 24559035
Dental health; Motivational interviewing; Clinical competence; Postpartum care; Prenatal care
3.  The Dental Neglect Scale in adolescents 
BMC Oral Health  2009;9:2.
Background
Dental neglect has been found to be related to poor oral health, a tendency not to have had routine check-ups, and a longer period of time since the last dental appointment in samples of children and adults. The Dental Neglect Scale (DNS) has been found to be a valid measure of dental neglect in samples of children and adults, and may be valid for adolescents as well. We administered the DNS to a sample of adolescents and report on the relationships between the DNS and oral health status, whether or not the adolescent has been to the dentist recently for routine check-ups, and whether or not the adolescent currently goes to a dentist. We also report the internal and test-retest reliabilities of the DNS in this sample, as well as the results of an exploratory factor analysis.
Methods
One hundred seventeen adolescents from seven youth groups in the Seattle-Tacoma metropolitan area (Washington State, U.S.) completed the DNS and indicated whether they currently go to a dentist, while parents indicated whether the adolescent had a check-up in the previous three years. Adolescents also received a dental screening. Sixty six adolescents completed the questionnaire twice. T-tests were used to compare DNS scores of adolescents who have visible caries or not, adolescents who have had a check-up in the past three years or not, and adolescents who currently go to a dentist or not. Internal reliability was measured by Cronbach's alpha, and test-rest reliability was measured by intra-class correlation. Factor analysis (Varimax rotation) was used to examine the factor structure.
Results
In each comparison, significantly higher DNS scores were observed in adolescents with visible caries, who have not had a check-up in the past three years, or who do not go to a dentist (all p values < 0.05). The test-retest reliability of the DNS was high (ICC = 0.81), and its internal reliability was acceptable (Cronbach's alpha = 0.60). Factor analysis yielded two factors, characterized by home care and visiting a dentist.
Conclusion
The DNS appears to operate similarly in this sample of adolescents as it has in other samples of children and adults.
doi:10.1186/1472-6831-9-2
PMCID: PMC2627830  PMID: 19123953
4.  Thinking about going to the dentist: a Contemplation Ladder to assess dentally-avoidant individuals' readiness to go to a dentist 
BMC Oral Health  2011;11:4.
Background
The Transtheoretical Model suggests that individuals vary according to their readiness to change behavior. Previous work in smoking cessation and other health areas suggests that interventions are more successful when they are tailored to an individual's stage of change with regards to the specific behavior. We report on the performance of a single-item measure ("Ladder") to assess the readiness to change dental-avoidant behavior.
Methods
An existing Contemplation Ladder for assessing stage of change in smoking cessation was modified to assess readiness to go to a dentist. The resulting Ladder was administered to samples of English-speaking adolescents (USA), Spanish-speaking adults (USA), and Norwegian military recruits (Norway) in order to assess construct validity. The Ladder was also administered to a sample of English-speaking avoidant adolescents and young adults who were enrolled in an intervention study (USA) in order to assess criterion validity. All participants also had dental examinations, and completed other questionnaires. Correlations, chi square, t tests and one-way ANOVAs were used to assess relationships between variables.
Results
In two samples, participants who do not go to the dentist had significantly more teeth with caries; in a third sample, participants who do not go to the dentist had significantly worse caries. Ladder scores were not significantly related to age, gender, caries, or dental fear. However, Ladder scores were significantly related to statements of intention to visit a dentist in the future and the importance of oral health. In a preliminary finding, Ladder scores at baseline also predicted whether or not the participants decided to go to a dentist in the intervention sample.
Conclusions
The data provide support for the convergent and divergent construct validity of the Ladder, and preliminary support for its criterion validity. The lack of relationship between dental fear and Ladder scores suggests that avoidant individuals may be helped to decide to go to a dentist using interventions which do not explicitly target their fear.
doi:10.1186/1472-6831-11-4
PMCID: PMC3045398  PMID: 21272356
5.  Behavioral Problems In The Utilization Of New Technology To Control Caries: Patients And Provider Readiness And Motivation 
BMC Oral Health  2006;6(Suppl 1):S5.
New research developments frequently are neither adopted by providers nor utilized by patients. This dual problem of impacting the behaviors of providers and patients presents a challenge. This paper will present behavioral theories and technologies that can be utilized to impact both provider and patient behaviors.
doi:10.1186/1472-6831-6-S1-S5
PMCID: PMC2147589  PMID: 16934122
6.  Additional psychometric data for the Spanish Modified Dental Anxiety Scale, and psychometric data for a Spanish version of the Revised Dental Beliefs Survey 
BMC Oral Health  2010;10:12.
Background
Hispanics comprise the largest ethnic minority group in the United States. Previous work with the Spanish Modified Dental Anxiety Scale (MDAS) yielded good validity, but lower test-retest reliability. We report the performance of the Spanish MDAS in a new sample, as well as the performance of the Spanish Revised Dental Beliefs Survey (R-DBS).
Methods
One hundred sixty two Spanish-speaking adults attending Spanish-language church services or an Hispanic cultural festival completed questionnaires containing the Spanish MDAS, Spanish R-DBS, and dental attendance questions, and underwent a brief oral examination. Church attendees completed the questionnaire a second time, for test-retest purposes.
Results
The Spanish MDAS and R-DBS were completed by 156 and 136 adults, respectively. The test-retest reliability of the Spanish MDAS was 0.83 (95% CI = 0.60-0.92). The internal reliability of the Spanish R-DBS was 0.96 (95% CI = 0.94-0.97), and the test-retest reliability was 0.86 (95% CI = 0.64-0.94). The two measures were significantly correlated (Spearman's rho = 0.38, p < 0.001). Participants who do not currently go to a dentist had significantly higher MDAS scores (t = 3.40, df = 106, p = 0.003) as well as significantly higher R-DBS scores (t = 2.21, df = 131, p = 0.029). Participants whose most recent dental visit was for pain or a problem, rather than for a check-up, scored significantly higher on both the MDAS (t = 3.00, df = 106, p = 0.003) and the R-DBS (t = 2.85, df = 92, p = 0.005). Those with high dental fear (MDAS score 19 or greater) were significantly more likely to have severe caries (Chi square = 6.644, df = 2, p = 0.036). Higher scores on the R-DBS were significantly related to having more missing teeth (Spearman's rho = 0.23, p = 0.009).
Conclusion
In this sample, the test-retest reliability of the Spanish MDAS was higher. The significant relationships between dental attendance and questionnaire scores, as well as the difference in caries severity seen in those with high fear, add to the evidence of this scale's construct validity in Hispanic samples. Our results also provide evidence for the internal and test-retest reliabilities, as well as the construct validity, of the Spanish R-DBS.
doi:10.1186/1472-6831-10-12
PMCID: PMC2887771  PMID: 20465835

Results 1-6 (6)