The process for development of the intervention
A multi-disciplinary team was established at Queen Mary University of London, Barts and the London Institute of Dentistry to develop the BBaRTS (Bedtime Brush and Read Together to Sleep) Children’s Healthy Teeth Programme. Continuing on from previous work [
23] the team wanted to develop attractive, colourful, age-appropriate storybooks as the platform for delivering behaviour change to parents to enhance their self-efficacy in relation to their child’s twice-daily toothbrushing and control of ‘sugar snacking’. A review of children’s storybooks in relation to oral health has been undertaken and most focused on visits to the dentist with little to no reference to preventive behaviours [
23]. Therefore, it was decided the focus of the books should incorporate preventive oral health behaviours and developmental changes (e.g. toothbrushing with fluoride toothpaste, controlling sugars in children’s foods and drinks; and losing primary teeth and growing new permanent teeth). Within existing children’s stories sustained situational interest can result in children developing a greater interest [
38]; therefore, it was decided that a series of storybooks, revisiting the same characters would sustain the greatest level of interest. Previous research suggests that 6- to 8-year-olds prefer cartoons [
39], so the style used was that of cartoon characters with vibrant colour schemes to attract young readers. It is noted that the books are designed to be read by parents to their child.
Initially two stories were written (Miles Salter) and illustrated (Pony Ltd.) in line with the brief above. Storybook 1 depicted anthropomorphised animal characters (frogs), Storybook 2 used illustrations of children dressed as animals (elephants). Both stories had easy-to-read, culture-neutral named characters, depicting toothbrushing behaviour and healthy food choices as a normal part of an exciting adventure story. To evaluate the appeal and acceptability of the storybooks, the research team organised focus groups in two London schools, with teachers and parents as well as children in class 1 (aged 5–6) and class 2 (aged 6–7), all of whom evaluated them.
Following analysis of focus group results and feedback it was decided that Storybook 1 should be taken forward as a concept for testing. In collaboration with literacy advisors at the DfE, the first two storybooks of the series of eight were written by Miles Salter (published author of children’s books), Sai Pathmanathan (science educator), Cynthia Pine (Professor in Dental Public Health) and Pauline Adair (clinical and health psychologist). Illustrations for the book were developed with local illustrators (Pony Ltd.) (
http://www.ponybox.co.uk/), experienced in children’s education and research materials.
Literacy advisors at the DfE supported the development of the books and provided advice about the phonics, rhyme, rhythm and repetition and framing of the stories around events in children’s lives. They advised that the books were not suitable for children to read alone, due to the reading level, but supported the books as those to be taken home and read by parents to their child at bedtime. This aligns with existing literacy schemes in schools by encouraging children to read with parents at home. DfE colleagues recommended questions and information to guide the adult readers. These were subsequently added to the back of the book. Advice was also taken on the age-appropriateness of the book content and how this should develop over the series of eight books as the children get older and their cognitive development changes.
A proof-of-concept study was conducted with the first storybook in four primary schools in London UK, with a range of socioeconomic profiles. Schools were selected by the DfE and consultants in dental public health colleagues. The schools were all in inner London with a very considerable range of diversity and significant numbers of children and families whose first language was not English.
On completion of consent forms children (
n = 144) were given a unique ID number, which was used for the duration of the study. Parents were given baseline questionnaires, adapted from existing oral health behaviours questionnaire [
13] and reading scales [
23] to complete and return to their child’s teacher. On return of the questionnaire each child was randomised to group 1 (Test) or group 2 (Control). Children in group 1 were provided with a copy of ‘
Boom and Bang with Zip and Pop’ [
40]. Children in group 2 (Control) were given a copy of ‘
Giraffes Can’t Dance’ [
41], a popular children’s storybook containing no dental health messages, but a positive story containing animal characters involved in dance. After 1 month all books were collected and an endpoint questionnaire was handed out to all parents of children enrolled in the study. Additionally, five focus groups were conducted in two of the schools to explore the children’s (
n = 28) opinions on books 1 and 2 of the ‘
Zip and Pop’ series and the outlines for the remaining books in the series.
In all, 105 families completed the study, 54 in the test group and 51 in the control group. Seventy-one (68 %) of the families were of non-UK origin, 34 (63 %) in the test group, and 37 (73 %) in the control group. On a five-point scale (1 = strongly disagree; 5 = strongly agree), most families found the stories in both books were well-understood (mean (SD) 4.30 (0.64) Test; 4.34 (0.49) Control). When asked if they agreed the story helped them talk about brushing their child’s teeth: UK-origin parents had mean response of 3.55 (0.60) Test compared to 2.29 (1.07) Control; with 3.41 (0.99) Test and 3.25 (1.08) Control for non-UK- origin parents. The mean response to whether the story helped UK-origin parents to talk to their child about healthy foods and drinks was 3.70 (0.47) Test compared to 2.07 (1.14) Control; but 3.69 (0.93) Test and 3.50 (0.96) Control for non-UK-origin parents. UK-origin parents’ responses to whether reading the storybook together has helped their child co-operate better with getting their teeth brushed were 3.10 (0.64) Test versus 2.14 (0.86) Control; but non-UK-origin parents were 3.42 (0.97) Test and 3.27 (0.84) Control.
The books were both well-accepted and the children were very reluctant to return the test books at the end of the study. Parents accepted the study principles, were willing to be randomised to groups and welcomed the opportunity of receiving free storybooks. The community engagement to the feasibility study was deliberately challenging in terms of testing feasibility of an intervention set in English. Discussion with teachers and assistants identified that the schools had chosen to send home all school material in English as a mechanism to promote engagement with language development. The schools had developed extensive systems to support English language development. It is evident from the results of this study that taking the books into a substantive trial is feasible, that although there are challenges in using this medium for behaviour change for non-UK-origin families, the support systems within schools provide a mechanism to enhance engagement with reading.