Families learning about toothbrushing: developing a scalable intervention

Background: Dental caries in children is a preventable condition. In Pakistan, despite high prevalence, there have been minimal efforts to address this public health problem. Aim: To develop and test feasibility of a behavioural intervention aimed at parents, delivered by Lady Health Workers (LHWs) for oral health promotion of children in Pakistan. Methods: The PhD used mixed methods approach following MRC guidance on developing and evaluating complex health interventions. The theoretical domains framework (TDF) provided theoretical underpinnings and COM-B model helped analyse drivers for behaviour change. Study 1: systematic review and meta-analysis for effectiveness of behaviour change interventions delivered by non-dental health workers for children's oral health promotion, to identify behaviour change techniques (BCTs). Study 2: focus groups to identify barriers & facilitators for children's toothbrushing and oral health promotion. Study 3: compilation and finalisation of intervention through identification of modifiable behavioural determinants, and patient and public involvement (PPI) to finalise the intervention materials. Study 4: feasibility study for feasibility assessment of intervention (LHW training, intervention delivery and fidelity), and evaluation methods (recruitment strategy, and data collection). Acceptability of intervention and perceived impact/sustainability explored using semi-structured interviews. Results: Systematic review identified 23 effective studies from which 18 individual BCTs were finalised to form the PROviding Support to Parents for Engaging in their Children's Toothbrushing (PROSPECT) intervention. The feasibility study recruited 7 LHWs and 34 mothers (>100% recruitment), and trained all LHWs who then delivered the intervention during home visits (n=34) with high fidelity. The data collection showed 91% response rate. An overall positive response reported by mothers and LHWs regarding intervention's acceptability, and perceived impact/sustainability. Conclusion: The results suggest incorporating toothbrushing advice as part of LHWs routine home visits as feasible and acceptable means to promote children's oral health in Pakistan. A definitive trial is needed to test intervention's effectiveness.