The basic research factors questionnaire for studying early childhood caries

Selected measures were refined by the measures working groups and forwarded in March, 2009, to the EC4 Steering Committee for final review. Table 2 provides the final set of essential CDEs (88 items) and includes explanations and scoring criteria. A total of 7 domains were deemed to be essential: oral health knowledge (15 items), oral health behavior (12 items), utilization/insurance & cost (29 items), parent/caregiver dental self-efficacy (11 items), pediatric oral health quality of life (12 items), caregiver and family characteristics (6 items), and child characteristics (3 items). Table 3 provides a list of optional CDEs (177 items) and their definitions.

Across the four trials, baseline BRFQ data were collected for a total of 3,265 caregiver participants (Table 5). The method of administering the BRFQ varied across centers; UCD studies have used an Audio Computer-Assisted Self-Interview software system; the BU and UCSF studies used Computer Assisted Personal Interviews. Because of these differences and because the number of optional items used determined the length of each Center’s survey, the average time required to complete the baseline BRFQ also varied. The average time taken by UCD study participants to complete the BRFQ was 37 min. BU study participants needed 45–60 min and UCSF study participants completed the assessment in an average of 25 min.

Most parent/caregiver participants who completed the BRFQ were women and most often were mothers of the children in the studies (Table 5). Twenty to 25% of participants completing the BRFQ had less than high school education, and in UCD and UCSF studies only about 10% had some college education or a graduate degree.

The UCD studies took place on tribal reservations and included several items specific to that population. For example, questions were asked about tribal identity and affiliation, and about dental care received through the Indian Health Service. In addition, UCD studies included more variables related to attitudes and psychosocial characteristics, including oral health locus of control [17] sense of coherence, chronic stress, perceived discrimination, distress, and financial stability (Table 3). The investigators felt that it was important to probe the extent to which reservation-dwelling populations, among whom caries rates are extraordinarily high, felt that they had some influence over the oral health of their children. Stress, discrimination, and financial stability measures had been developed and productively used in other studies of American Indian health issues [10, 18], showing that stress is common among American Indian populations living on reservations [18].

The health literacy item used by the BU and UCSF studies (Table 3) was the well-accepted Single Item Literacy Screener [19], which has been cited in over 300 papers. During the measures pilot, UCD study investigators found that in their population the health literacy item was not related to education or income/poverty, constructs that are generally very reliably related to health literacy. Further, the item showed limited variability, with 84% of participants reporting no difficulty with reading medical materials, despite lower levels of educational attainment among American Indian populations. Based on these findings and the fact that the item itself has a relatively high degree of reading difficulty, UCD replaced the Single Item Literacy Screener with slightly adapted versions of three well-validated health literacy screening items [20, 21]. In the UCSF quality management assessment pilot of 40 parent-child dyads, staff found that using a flip chart to display response options improved administration flow in case participants did not remember them. Following the UCSF pilot, the response option of “less than 1 year old” was added to the question about age of child at first dental visit and Spanish translations were refined for clarity. The BU pilot consisted of cognitive interviews of 36 individuals (20 in English and 16 in Spanish) to ensure that the BRFQ was culturally appropriate and at the appropriate literacy level. Similar to the UCSF pilot, the BU study also found that utilizing a flip chart of responses facilitated data collection. To ensure that the final surveys would be as consistent as possible across Centers, decisions about final item refinements were determined collaboratively.

In addition to measuring self-efficacy and perceived importance, BU assessed motivation to engage in a variety of oral health recommendations and reduce ECC (Table 3). The measure was designed to assess the effects of their intervention, which was based on Motivational Interviewing. MI techniques attempt to build motivation by helping participants weigh the pros and cons of change, discussing the discrepancy between their behaviors and values/goals, and helping participants look forward to the positive changes that could result from initiating and sustaining pediatric oral health behaviors.

BU also measured caregiver stress using the Hassles Scale. Previous research has shown that daily hassles may create even more stress than traditional measures of stress focused on major life events [22]. Their predictive value has been shown in low-income populations [23] and in the context of health outcomes [24].

BU and UCSF used the revised multidimensional Acculturation Scale for Mexican-Americans (ARSMA-II) acculturation scale, which measures the degree to which participants are culturally tied to both Anglo and Hispanic communities [25]. Acculturation is correlated with years since immigration and age at immigration. Investigators wanted to be able to include acculturation as a possible effect modifier of the interventions. In addition, UCSF asked about child’s birthplace.

Both BU and UCSF included additional oral health knowledge questions beyond the essential set to ensure that there were knowledge questions that mapped directly to their intervention. For example, BU included questions regarding knowledge about timing of first dental visit and bedtime sippy cup use. UCSF asked additional questions related to its intervention including fluoride exposure, and application of fluoride varnish and dental sealants.