Developing a prototype home-based toothbrushing support tool for families in Scotland: a mixed-methods study with modified Delphi survey and semi-structured interviews

Background: Scotland’s National Oral Health Programme for Children, Childsmile, provides targeted home toothbrushing support for families of young children (0-3yrs) in the home setting. The study describes the adaptation of an existing dental practice-based intervention from the Netherlands using pictorial cards (Uitblinkers) for use in the programme. The aims were to modify Uitblinkers for the setting and context in Scotland by: 1) identifying the barriers that parents/carers in need of extra support face in implementing supervised toothbrushing; 2) explore consensus about behaviour change techniques that are appropriate and valid to address these; and 3) making recommendations for design of a co-produced home-support tool and identifying facilitators for implementation in practice.

Methods: A Modified Delphi study was carried out consisting of two survey rounds with a purposively recruited expert panel (n=21) to develop consensus on home toothbrushing barriers (aim 1), behaviour change techniques (aim 2), and considerations for implementation (aim 3). Proposition statements for the Delphi were derived from literature, discussions with project advisors, and from Uitblinkers, an existing behaviour change intervention for parents developed by the Academic Centre for Dentistry Amsterdam (ACTA) and delivered in dental practice. Then 12 in-depth, semi-structured interviews were conducted with Dental Health Support Workers in Scotland (delivering the home support toothbrushing intervention) to gather the views on the proposed toothbrushing barriers, behaviour change techniques and considerations for implementation (aim 1 to 3). Delphi results are presented descriptively in terms of percentage agreement and priority ratings. Interview transcripts were analysed using Template Analysis.

Results:
From the Delphi study, a final set of 11 overlapping child, parent and environmental/social toothbrushing barriers was agreed upon (aim 1), to be addressed through a tool based on applied Motivational Interviewing, and a combination of Operant Conditioning, Stimulus Control, and Goal-Setting techniques (aim 2). Experts supported the tool as realistic for delivery in the home setting, provided staff were trained. A physical ‘paper’ tool was preferred to a proposed electronic version (aim 3). Themes from interviews were: 1) the barriers present an exhaustive set and are valid from staff experience with families; 2) Motivational Interviewing is appropriate and fits with usual practice; 3) the included behaviour change techniques are workable; 4) the tool is generally feasible within the operation of Childsmile home visits; 5) the tool is not less applicable for children with additional support needs.

Conclusions: A card-based conversational intervention to provide targeted home toothbrushing support for families of young children (0-3yrs) in the home setting in Scotland, drawing from a template from the Netherlands, has been deemed worthy of further testing based on expert consensus and staff views on barriers faced, appropriate behaviour change techniques to address these, and design of a physical tool.