Oral health promotion practices: a survey of Florida child care center directors

The number of child care facilities in the U.S. rose from 262,511 in 1987 to 766,401 in 2007, indicating an increasing trend in the establishment of such facilities [1]. There were 32.7 million children in ‘out-of-home’ child care facilities in year 2011, of which most (20.2 million) were aged 5–14 years; while the remaining 12.5 million were aged 0 to 4 years [2]. Preschoolers of employed and non-employed mothers spent approximately 36 h and 21 h respectively per week in these facilities [2]. Because a significant proportion of children spend so much time in these facilities, health intervention and promotion programs can be implemented in these settings to promote the health of the enrolled children.

One significant public health problem is an ongoing epidemic of dental caries in the U.S. children. The 2011–2012 National Health and Nutrition Examination Survey data showed that at least 40% of 2 to 8 year old children experienced dental caries in their primary teeth, with at least 14% having untreated tooth decay, suggesting that despite needing dental care, it was not received [3]. Approximately 21% of children ages 6 to 11, and 53% of adolescents aged 12 to 19 years had experienced dental caries [3]. This national data suggests that children develop dental caries all through their childhood.

Since many children spend a portion of their day in CCCs, centers provide an ideal setting to adopt measures to prevent dental caries, especially since most children enrolled in CCCs fall into the susceptible age range for dental caries. CCCs and childcare center directors (CCCDs) could take an active role to prevent dental diseases and promote oral health of all children enrolled in these centers by educating children and their parents about the importance of maintaining proper oral health, and adopting good oral health promotion practices (OHPPs) [4].

The American Academy of Pediatric Dentistry (AAPD) recognizes the importance and impact of oral health promotion within CCCs, based on children’s increased utilization of and time spent in these facilities for daily care [5]. The AAPD released a set of oral health guidelines addressing dental disease prevention and oral health promotion in out-of-home child care settings targeting CCCs, pediatric dentists, other health care professionals, legislators and policy makers [5]. This policy encourages CCCs to implement oral health promotion practices (OHPPs) to reduce a child’s risk of acquiring early childhood caries and the risk of dental trauma within their centers.

Very few studies have assessed the oral health related policies and regulations in daycare or childcare centers in the U.S. [6‐8]. Little is known about licensed CCCs in the state of Florida, and the type of OHPPs implemented within these centers. Florida CCCs provide a unique opportunity to explore oral health promotion practices because children in Florida experience poorer oral health and lack adequate dental care access compared to children in many other states [9]. Therefore our study surveyed child care center directors (CCCDs) employed in Florida licensed CCCs to determine which of the 8 selected AAPD recommended OHPPs were already implemented, and the factors associated with a higher number of OHPPs implemented. Because evidence [10] shows that children in CCCs affiliated with Head Start [HS] programs are significantly more likely to receive health care screenings and consultations compared to non-HS programs, we tested if there was any association between number of OHPPs implemented and the CCC’s affiliation with Early Head Start/Head start (EHS/HS) programs. EHS/HS programs are federal programs that promote school readiness among low-income children 0 to 5 years of age. These programs offer comprehensive early child hood education, health care services, nutrition, and parental involvement services. Many EHS/HS programs are based in preschools, and others are located in licensed childcare centers or family childcare homes.

The mean age of the CCCD respondents was 48.5 ± 10.5 years and they had mean years of experience of 11.6 ± 9.3 years. A majority of the study participants were women (96%) and belonged to the White race (74%). Approximately 19% of the sample was Hispanics. The majority (65%) reported having a college degree or higher. More than 60% reported earning an annual income of less than $50,000, with just over 20% reporting an income of $50,000 and above. Only 5% of the responding CCCDs reported that their center was affiliated with EHS/HS programs.

On average, participants answered only one knowledge question out of 3 correctly [Knowledge score: 1.3 ± 0.8 (mean ± SD)]. When asked if age 1 was the correct age to initiate cleaning a child’s teeth, only 1 in 5 correctly answered “False”. Only 2 in 5 CCCDs correctly answered that the child’s first dental visit should not be at 2 years. However, an overwhelming 85% of the respondents correctly identified that tooth decay or cavities is the most common childhood disease.

The mean attitude score (16.8 ± 2.7) suggested that CCCDs had positive attitudes towards pediatric oral health. Most of the respondents (94%) believed that cleaning baby teeth was very important. Only 9% felt that that there were too many activities at the center to devote any time to children’s dental health. Most (87%) felt that teaching children younger than 3 about the importance of oral health was not difficult. More than 65% believed that providing oral health promotion activities in CCCs will prevent dental caries.

CCCDs did not perceive that there were too many barriers to implementing OHPPs in their centers (mean SPB score: 1.55 ± 1.64). Funding issues (38.5%) and lack of oral health promotion training for staff (32.7%) were the most frequently reported self-perceived barriers by CCCDs. Less frequent barriers were lack of time to address oral health (24.7%), infection control issues (15.2%), lack of space to promote adequate oral health (14.1%), and negative parental attitudes (11.6%). Few CCCDs perceived parent’s language barriers (6.6%), cultural issues (5.4%), or other issues (2.5%) to be significant barriers to providing OHPPs in their center.

Figure 1 illustrates the percentage of respondents reporting about the implementation of 8 OHPPs in their centers. Slightly more than half of CCCDs reported that they promote the dental home concept to parents (53%) and provide optimally fluoridated water to children (53%), while the least implemented OHPPS were having an oral health emergency manual on site (8%) and maintaining children’s dental records (5%). On average, CCCDs reported implementing only 2.1 ± 1.6 (mean ± SD) out of 8 possible AAPD recommended OHPPs in their CCCs.

Understanding the oral health promotion practices in Florida licensed CCCs is important because these centers can be utilized as alternate non-traditional settings to promote optimal oral health of children. So we conducted a survey of CCCDs in Florida licensed CCCs to examine whether their center implemented any OHPPs, and if their center’s affiliation with EHS/HS programs affected the number of OHPPs implemented.

Of the 8 OHPPs assessed, our findings indicate that, on average, CCCDs reported implementing very few OHPPs in their centers, suggesting that OHPPs may not adequately practiced in these centers. More than 80% of the CCCDs reported that their enrollees did not brush after meals, their center lacked an oral health consultant and oral health emergency manuals, the staff were not trained in traumatic dental injuries, and did not maintain children’s dental records. This indicates that, based on the CCCDs’ reports, AAPD recommended oral health prevention and promotion activities were not frequently practiced in licensed Florida CCCs. In fact, a substantial number of children younger than 5 years old were enrolled in these centers at the time of our study (more than 80%), which is problematic because this age group has high dental caries risk and oral health promotion should already be initiated. At least in this study, we did not find any association between CCCD’s oral health knowledge and the number of OHPPs implemented. However, possessing correct oral health knowledge and high oral health literacy is important for CCCDs to practice appropriate OHPPs not only for themselves but also to implement into that childcare system that will benefit the enrolled children. Therefore Florida CCCDs need more education about the importance of implementing OHPPs within their CCCs, along with the long-term impact it can have on a child’s overall health and well-being. However, it was encouraging to find that most participants (67%) reported that they might implement OHPPs in the upcoming year.

To test our hypothesis and to determine factors associated with more implemented OHPPs in Florida CCCs, we conducted an adjusted Poisson regression model that yielded interesting results. Our study found that CCCDs working in EHS/HS affiliated centers implemented more OHPPs compared to their counterparts (p < 0.001). We conclude that there was a significant association between the number of OHPPs implemented and the center’s affiliation with EHS/HS programs. Literature supporting this result exists, with HS centers promoting health considerably more frequently than non-HS centers [10]. In a multi-state survey a higher proportion of responding CCCDs in HS centers reported consulting health professionals and screening for health problems in enrolled children, compared to their counterparts. This is due to greater awareness about pediatric health, and CCCDs in HS centers may attach greater importance to children’s health issues [10]. More experienced CCCDs may have been more confident and efficacious compared to inexperienced CCCDs, and therefore may have implemented more OHPPs. CCCDs with positive pediatric oral health promotion attitudes were more likely to report implementing OHPPs in their centers. Evidence suggests that those with more positive attitudes about health maintenance are more likely to adopt and practice healthy behaviors for their own well-being [16]. Prior research supports the idea that more barriers (perceived and real) impede prevention program implementation [17]. The most frequently reported barriers to implementing OHPPs by study participants were: 1) insufficient funding to implement oral health programs, 2) insufficient staff training about oral health promotion, and 3) insufficient staff time for pediatric oral health promotion. Previous literature has shown that these three elements are critical to the success of any health promotion or disease prevention programs in CCCs. Therefore we recommend that CCCDs identify strategies to overcome these three barriers to health promotion. Additional open-ended responses provided insights into other potential barriers faced by CCCDs when implementing OHPPs including: dentists rarely treating and educating children younger than 3 years, few community dentists, and there is no need to enforce oral health promotion at the center because it is not required for Florida’s licensure.

Ours is the first study to survey CCCDs in Florida on relevant OHPPs in their centers. Therefore our study highlights for the first time, the status of licensed CCCs in Florida and the lack of adequate oral health promotion in these settings. Limitations of this study include but are not limited to low response rate, use of a convenience sample, and induced bias due to selective participation. Therefore our study results should be interpreted with caution. Only 5% of the respondents reported working in EHS/HS affiliated centers compared to their counterparts (95%). A previous study showed very similar findings, with only 10% of the responding CCCDs reporting to work at HS affiliated centers [10]. We did not find information about the proportion of licensed CCCs in Florida that were affiliated with EHS/HS programs and therefore we were unable to determine if non-EHS/HS CCCDs were more or less likely to participate in the survey compared to their counterparts. A very small proportion of the respondents were males. Other types of childcare facilities, such as non-licensed CCCs, group childcare homes or family child care homes, were not explored because we did not have access to these facilities. Understanding the demographic differences between respondents and non-respondents could not be accomplished because the researchers did not manually track the participants as deemed by the IRB guidelines. Due to the limited funds to execute this study, postal surveys were not economically feasible.

Because the EHS/HS affiliated centers implement more OHPPs, we believe that EHS/HS programs may serve as a model that can be integrated into non-EHS/HS affiliated programs. Because many children receive daycare in CCCs, it is imperative that policy makers and State Departments of Health focus on policies and regulations that will improve the integration of OHPPs into these settings. For example, in the State of Florida, the child care licensing program is a component of the services provided by the Department of Children and Families. This program through regulations and consultation ensures that licensing requirements are met by the childcare facilities thus preventing operation of substandard childcare programs. Such departments can add mandatory regulations related to maintaining certain oral health standards in CCCs. By doing so, optimal oral health in children can be achieved by all CCCs. Child care centers are non-traditional alternate settings where new disease prevention and health promotion programs can be implemented to improve the health of enrolled children. These settings are excellent resources to apply oral health intervention programs, provided there are few barriers.

We conclude that affiliation with EHS/HS programs is associated with the number of OHPPs implemented licensed Florida licensed CCCs. In addition, CCCDs years of experience, attitudes towards oral health, and self-perceived barriers in implementing OHPPs were also associated with number of OHPPs implemented.