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Stage one: preparatory meetings with healthcare professionals and collation of examples of good practice
A pool of 18 stakeholders and health care professionals were approached to provide the resources they use at the 9–12 month visits. The research team delivered a one-day training event (which was delivered on two separate occasions), for health visitors where they introduced the HABIT project, discussed the need for resources, and collected attendees’ feedback on what type of support or aids would facilitate their day-to-day practice. In addition, individual meetings with health visitors, senior dental public health managers, members of oral health promotion teams, senior oral health improvement practitioners and health improvement facilitators were arranged to discuss their perspectives and the resources they use.
Over the course of two months, nine resource sets were collected from eight services across England. Some of the stakeholders reported absence or limited availability of oral health resources used at the 9–12 month universal visits. Instead, they shared resources that are used at some point between conception and child age of 30 months, therefore they were using more generic material and not using resources that were specifically targeted for the 9–12 month age range.
The shared resources fell broadly under two categories: those for use in a group setting and those for use on a one-to-one basis. With regard to group-facing resources, these were provided by one service that is geographically located in areas with high levels of dental disease in children. The team who shared this resource set noted that due to financial cuts oral health training for groups of parents had been cancelled, thus the resource set in question has not been used for some time. Nevertheless, they emphasised that health visitors and parents used to find it particularly helpful for facilitating oral health conversations and introducing optimal oral health behaviours. With regard to the one-to-one resources, these varied from a single A5 leaflet to models of teeth for toothbrushing demonstration. The majority of stakeholders noted that they shape oral health conversations around leaflets and items related to optimal oral health (conversations around free-flow cups, for example). Others, however, reported that in recent years the availability of resources has decreased significantly. Consequently, those who had no resources reported borrowing publicly available resources used in neighbouring localities. Others noted that a toothbrush and toothpaste were the only resources they had (used for demonstration only and were not given to parents). Despite the difference in resource availability, all stakeholders emphasised the value of appropriate oral health resources in encouraging parents to brush their child’s teeth, thereby optimising oral health behaviours.
Stage two: co-design workshops with parents and health visitors
A total of three workshops with 14 parents of children aged 9–12 months, and a total of three workshops with 15 health visitors were undertaken. An additional six interviews were conducted with three parents and three health visitors. Interviews and workshops took place between June and October 2017.
Findings from parent workshops and interviews
The information and support provided to parents was varied, with many parents stating that they had received little information about oral health directly from their health visitor. Several parents, however, suggested that they would have liked more advice at the time, with others stating that they felt they needed support sometime after the visit as their child grew older. Parents obtained oral health information from a variety of sources, including online websites, peers and family members; and only rarely was advice sought or received from dental professionals. Difficulty finding a dentist to register with in the local area was often cited as a barrier to obtaining information about oral health for their child. Participants agreed that information about oral health would be useful, particularly for first time parents, around the time that teeth first erupt.
Feedback upon the existing written resources collected in Stage One was that improvements could be made. Parents highlighted the importance of being provided with key messages that were easy to read, without too much detail or too many pictures, which distracted from the content.
“For me it’s, this is just all a bit too stimulating and there’s just too much going on. You know, there’s stuff to read everywhere and pictures everywhere.” (Parent)
Priorities for the content of key messages included what age to begin brushing, information on when parents should first attend the dentist with their child, weaning support and healthy eating advice. Parents also highlighted the need for practical information about how to brush.
“When they should start doing it, what you should use, what’s the best thing to use, how to do it. Step-by-step.” (Parent)
Some parents identified how their child’s challenging behaviours may become a barrier to PSB and suggestions around how to overcome these behaviours was important.
“And…yeah some acknowledgement that it may not be straightforward then I think that, I think that would be helpful actually” (Parent)
Parents varied in their preferences about how resources on oral health should be provided; some preferred for the information to be written, in the form of a leaflet, and others stated a preference for electronic resources, such as websites or videos. However, a consistent theme was the need for all the necessary information to be presented in one place, in a concise fashion. Many parents identified the importance of the oral health discussion with the health visitor, which would encourage them to engage with the resources and or retain for future use:
“I think it’s better a person telling you rather than a leaflet telling you” (Parent)
The way in which information was delivered was particularly important to some parents who prioritised the importance of having an open, non-judgemental conversations with their health visitor:
“And [health visitor] tells me in a very sort of patronising way, you know, the way that she presents information… And that, that really has put me on the defensive.” (Parent)
Parent’s experience of conversations with health visitors appeared to contribute significantly to their perceptions of the usefulness of the service and information provided by health visitors. Experiences varied significantly with some parents viewing the contacts as more of a ‘tick box’ exercise and others placing significant value upon the support and information received from their health visitor.
Findings from health visitor workshops and interviews
Health visitors who participated in the interviews and workshops highlighted the high levels of tooth decay experienced by children in their local area. They perceived facilitating good oral health to be an important aspect of their role. Often their conversations were initiated by giving out a toothbrushing pack (consisting generally of toothbrush and toothpaste). There was variation in the level of detail given to families about oral health and health visitors described how information may be prioritised depending upon the particular circumstances of each family. For example, the discussion may focus more on healthy eating if the health visitor noticed that the child was being given sugary foods or drinks.
One difficulty identified by the health visitors was the number of topics which needed to be covered within the 9–12 month visit. Some felt that they did not have enough time to cover the topic of oral health in detail:
“…we don’t really focus on it. You know, we touch on it, ‘are you registered, you know? You need to brush their teeth, you need to use this much toothpaste on a soft brush’ and, you know, that’s pretty much it, you know. It is a bit of a sort of whistle stop…” (Health visitor)
“So if, if a parent comes in with a specific problem, it might be about sleep or something, you do devote an awful lot of time to that. And then other things, it’s kind of a quick mention. So I think that, that’s a real difficulty isn’t it.” (Health visitor)
Information about oral health was predominantly delivered verbally. Health visitors described the limited availability of resources to support conversations about oral health:
“So I don’t know whether it’d be a leaflet or, or something. We don’t sort of have anything like that for them to sort of keep or to refer back to…” (Health visitor)
Feedback was obtained on the resources collected during Stage One. Health visitors valued resources which were visually engaging (i.e., bright, colourful) and those with pictorial representations. They felt that many of the existing resources were overcrowded with text and/or pictorial information and stated a preference for the resources to contain ‘key’ information only, in a ‘bullet point’ style. The size of the resources was also important; many health visitors suggested that resources should not be heavy or bulky for them to carry and suggested that ‘pocket size’ would be ideal.
“It needs to be small as well cause we all carry heavy bags don’t we.” (Health visitor)
The health visitors identified that personal preference was likely to play a role in families’ attitudes about different resources. For example, some may prefer written information in the form of a leaflet and others may prefer electronic resources (such as a website or videos). The availability of resources in different formats was also perceived to promote accessibility, for example; some parents may be unable to read a written leaflet but may be able to access or prefer video resources.
“Cause I don’t, as you were saying, leaflets don’t always work for parents. They think oh yeah, yeah, oh, another leaflet. It’ll just go in the bin.” (Health visitor)
“And, you know, if there is a good website that you can signpost to them I’m more than happy to do it, you know…” (Health visitor)
Some of the health visitors, especially those who work with families living in the most deprived areas, mentioned that some parents would not be able to access the online resources and thus would be denied an opportunity to learn how to ensure their child’s oral health.
One suggestion made was that a set of model teeth might be useful on which to demonstrate the action of toothbrushing:
“…we could have a little, a little teeth with their brush and show them how to do it.” (Health visitor)
Stage three: resource development and expert / peer review
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a)
Resource Development
As discussed, the parents felt that a supportive conversation with health visitors was the most important part of the oral health component of their visit. This conversation should be accompanied by appropriate resources to supplement the discussions.
Informed by the preceding research work, and findings from the workshops and interviews, six broad topic areas were identified to form the basis of the HABIT resources. The topic areas are listed below, with a brief explanation of the key message/s.
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1)
No Second Chance—(Why oral health is important and consequences of dental decay)
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2)
Toothbrushing Knowledge (Toothbrushing advice, e.g., twice daily with a fluoride toothpaste, strength and amount of fluoride toothpaste to use and parental supervised brushing until at least the age of seven)
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3)
Toothbrushing Skills (Support and tips for brushing children’s teeth, e.g., positioning options and techniques for effectively brushing a child’s teeth, systematic approach and brushing all surfaces of the teeth)
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4)
Managing Behaviour (Providing reassurance that brushing children’s teeth is often challenging and providing tips to make brushing easier)
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5)
Diet Knowledge (Information around healthy food, drinks and snacks, frequency of sugar, advice to only drink milk and water and use of a free flow cup over 6 months of age)
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6)
Social Influence (Empowering parents to work with other family members involved in their child’s care around the importance of brushing children’s teeth)
The key messages provided in the resources were informed by Stage One and Two of the project and the previous programme of research, which highlighted the individual, social and structural factors that influence PSB [38, 40,41,42]. The key messages aimed to facilitate behaviour change by targeting the potential barriers to PSB including knowledge, skills, self-efficacy, routine setting and behavioural regulation.
The key messages provided a structure for the supportive materials and resources which were designed in two formats; a leaflet and a website. First, a fold up, pocket-sized leaflet, which contained short sentences of essential information on each of the six key topic areas. At the back of the leaflet was an action plan, which consisted of a list of positive oral health behaviours, e.g., ‘Brush my baby’s teeth twice a day with a fluoride toothpaste’ and ‘Avoid sugary foods and drinks an hour before bedtime’. The action plan was provided to aid behaviour change as parents could choose one or two key areas to focus on, and in conjunction with the health visitor, discuss how to achieve this goal. Based upon feedback from Stage Two of the project, text was kept to a minimum and the leaflet was designed to be colourful (a different colour associated with each key message) and engaging (one simple illustrative picture per message).
Second, a website housing short two-to-five-minute video vignettes on each of the six key message topics was developed. The video vignettes included key messages from Public Health England’s ‘Delivering Better Oral Health’ toolkit [47], demonstrations, practical examples and tips, as well as parents sharing their own stories, challenges and solutions. These stories include parents from different backgrounds to maximise their appeal and engagement with different parent groups. The involvement of parents within the video came from earlier community engagement work. These peer stories, which other parents could relate to were identified by local communities as being far more powerful than messages from a dental professional. The website was designed to coordinate with the leaflet and the colours and pictures associated with each key message were consistent on each. The address for the website was also printed on the front of the leaflet to encourage parents to visit the website and for health visitors to promote it as a trusted source of information.
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b)
Expert/Peer review
HABIT resources were reviewed by a Consultant in Public Dental Health, who was also the National Lead for Oral Health Improvement and two Senior Dental Public Health Managers, all employed by Public Health England. These colleagues provided national leadership to the area of oral health promotion and were responsible for writing and updating the national oral health guidelines [47]. Their detailed feedback was to ensure that key messages aligned with their published materials. The resources were also reviewed by a group of 25 healthcare colleagues from the 0–19 Healthy Child Programme in Yorkshire and the Humber. The comments received from both groups focused on (i) subtle changes in language; (ii) providing positive examples such as multiple clips of different parents brushing their child’s teeth, use of a two toothbrush technique so that the child has something to hold while their teeth are being brushed, squirting out food pouches into a bowl and providing examples of healthier snacks for teeth; (iii) explanations around what is a free flow cup and at what age these should be used from and when the use of a bottle should be stopped; and (iv) ensuring the HABIT resources aligned with wider public health activities such as Dental Check by One and providing captions aligning to key messages such as “squashes and fizzy drinks have no place in children’s diets”.
Stage four: development of an intervention protocol for health visitors
Eight health visitors attended a training day on the HABIT intervention. The health visitors watched a series of novel television-based programmes developed by “SOAP” designed to support early-years professionals’ oral health knowledge (www.soap.media). These innovative resources had been reviewed by Public Health England to ensure they were compliant with current national guidance [47]. The programmes focused on different age groups (0–2 year olds, 2 year olds, 3–4 year olds), and discussed with a panel of health experts and parents key issues pertinent to each age group. After viewing each programme, in small groups, the health visitors reflected on and discussed what they had seen. Moreover, they had a chance to discuss any questions they had with a dental hygienist and therapist, and a paediatric dentist from the research team.
The health visitors then viewed the HABIT resources and videos, providing an opportunity to discuss the resources and their implementation. The health visitors worked with the research team to agree upon a delivery protocol (a standard format) on how the HABIT intervention would be delivered. Health visitors raised key features they wanted included within the protocol including: the importance of the initial oral health conversation; a visual hands-on demonstration of toothbrushing technique, either with the child or on a plastic set of teeth; and for the conversation to identify and focus on the oral health issues, which were most important to parents. A simple, five stage protocol was finalised to guide delivery of the oral health conversation during the 9–12 month visit. This included;
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1) Handing out the dental pack consisting of a toothbrush, toothpaste and HABIT leaflet, and starting the conversation about toothbrushing.
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2) Asking parents to brush their baby’s teeth and then provide a demonstration of toothbrushing technique (using a set of plastic model teeth if a hands-on demonstration wasn’t possible due to lack of cooperation from the child).
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3) Identifying and discussing the most important issue to parents regarding oral health and supporting patents to identify their own solutions to overcome challenges faced.
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4) Signposting to the leaflet, website and videos, using these to guide and support the conversation between health visitors and parents.
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5) Encouraging parents to create an action plan and recording how they intend to implement their plan over the next two weeks. The action plan was written on the HABIT leaflet, which contained suggestions of areas parents may wish to focus on. These included: ‘using a smear of fluoride toothpaste’, ‘stick to milk and water to drink’, ‘make toothbrushing as fun as possible’. However, space was provided to allow parents to create unique goals should they so wish.
The one-day training session aimed to ensure all health visitors delivering the HABIT intervention had up-to-date oral health knowledge in line with national guidelines [47] and all had participated and agreed on how it would be delivered. The discussions during the day led to the finalised protocol to guide the delivery of the HABIT conversation between health visitors and families. A structured diary was finalised as a method of recording how the visit went, the consistency of intervention delivery, what resources were used and provided an opportunity to reflect on their conversations after each visit. Additional File 4 provides the TiDieR checklist outline the HABIT intervention as delivered throughout the feasibility study.
Stage five: early-phase testing of the resources to explore acceptability, feasibility, impact and mechanism of action
Detailed findings from the HABIT early-phase feasibility study are beyond the scope of this paper and are reported in separate publications [35,36,37]. In summary, the feasibility study identified that the HABIT intervention was acceptable to parents, feasible for health visitors to deliver and provided a strong signal of improved PSB behaviours at three months after the intervention. Parents felt their health visitors were trusted people from whom they were happy to receive the intervention. The parents felt that the intervention provided them with the support and encouragement to know that they were doing the right thing, e.g., starting to brush their baby’s teeth on eruption of the first tooth. Both health visitors and parents highlighted how important the timing of advice provision was and health visitors discussed that oral health information integrated well into their existing conversations about health promotion. A number of refinements were identified which are discussed together with findings from stage six.
Stage six: engagement with wider stakeholders and refinement of the HABIT intervention for wider use
Following the completion of the early-phase feasibility study, preliminary results were presented at a dissemination event. Sixty-six delegates attended, including some of the health visitors who had delivered the HABIT intervention as well as many other health and early-years professionals including representatives from: Bradford District Care NHS Foundation Trust Research, Health Visiting and Dental teams, Public Health England, Bradford Local Authority, Born in Bradford/Better Start Bradford, Oral Health Promotion Group, British Society of Paediatric Dentistry and University of Leeds.
As part of the dissemination day, the delegates reviewed the HABIT resources in small groups and provided valuable additional feedback in the form of what they would ‘Keep’, ‘Improve’ and ‘Lose’. There were very few comments relating to aspects that people wanted to ‘Lose’ from the resources, however, there were various elements that were liked and several areas where improvements could be made. Feedback included; improvements to format of the leaflet, increased font size, or highlighting particular information to be more prominent. The videos were well received, with some delegates commenting that they felt true to life with good examples of parenting tips or safer snacks. Some delegates provided very constructive feedback suggesting improvements to the clarity of certain aspects of advice, as some visual elements could be misunderstood without the supportive audio. For example, when foods and drinks that are not safe for teeth are shown in the video, without the supportive audio, these could be seen as acceptable for children to consume as they are in an oral health video.
The event also enabled delegates to review the results and discuss how to take the HABIT intervention forward. Comments provided on the day included: widening the accessibility of the videos, such as translating the resources into other languages and the use of subtitles on the videos, suggestions for less written text and more visuals to support the language barrier concerns; there were requests for additional links from the website to other useful resources and some requests for the inclusion of more toothbrushing demonstrations to highlight the correct techniques.
There were two main areas identified as needing further development before progressing to a definitive study or trial:
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1.
HABIT resources:
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updating of the consent of parents and their children to continue to appear in the HABIT videos;
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working with key local communities, with high levels of early-childhood decay, to ensure the videos and resources were appropriate, for example, if English was not a first language and to comply with other accessibility guidance [49]; and
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address the utility of the HABIT intervention to enable them to support different universal mandatory home visits that health visitors undertake for children aged 0–30 months.
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2.
Health visitor training – feedback from the dissemination day and the qualitative interviews with health visitors and parents identified inconsistencies in the delivery of the HABIT intervention [36, 37]. Refinements to the HABIT training include preparation work for the delegates before they attended, such as watching the online SOAP resources, HABIT videos and videos showcasing examples of “effective” HABIT conversations. This provided additional time during the training for health visitors to practice the structure of the “HABIT” oral health conversation using forum theatre, a type of role-play involving actors and reinforce the importance of signposting parents to the online HABIT resources and the use of the action plans. Furthermore, the training would provide further opportunities to work with health visitors to identify how best to monitor the fidelity of these conservations.
Stage seven: verification, review and reflection of resources
The HABIT videos, leaflet and website were reviewed and verified against the Theoretical Domains Framework (TDF) [43, 44] and Delivering Better Oral Health [8] guidance. Each resource was independently coded by two researchers who then subsequently met, reviewed their coding, and agreed on any dissimilarities [48]. The findings of this exercise showed that all 12 of the TDF domains were addressed across the HABIT resources which aligns with the findings from the initial work to identify the barriers to PSB [40,41,42]. Similarly, all oral health messages were consistent with Delivering Better Oral Health guidance, and the majority of guidance points were covered with the exception of breast feeding and the application of fluoride varnish at dental appointments (see Additional File 5 for a copy of the summary table of the mapped domains).
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