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Marshman Z, Ainsworth H, Fairhurst C, Whiteside K, Sykes D, Keetharuth A, El Yousfi S, Turner E, Day PF, Chestnutt IG, Dixon S, Kellar I, Gilchrist F, Robertson M, Pavitt S, Hewitt C, Dey D, Torgerson D, Pollard L, Manser E, Seifo N, Araujo M, Al-Yaseen W, Jones C, Hicks K, Rowles K, Innes N. Behaviour change intervention (education and text) to prevent dental caries in secondary school pupils: BRIGHT RCT, process and economic evaluation. Health Technol Assess 2024; 28:1-142. [PMID: 39258962 DOI: 10.3310/jqta2103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2024] Open
Abstract
Background The presence of dental caries impacts on children's daily lives, particularly among those living in deprived areas. There are successful interventions across the United Kingdom for young children based on toothbrushing with fluoride toothpaste. However, evidence is lacking for oral health improvement programmes in secondary-school pupils to reduce dental caries and its sequelae. Objectives To determine the clinical and cost effectiveness of a behaviour change intervention promoting toothbrushing for preventing dental caries in secondary-school pupils. Design A multicentre, school-based, assessor-blinded, two-arm cluster randomised controlled trial with an internal pilot and embedded health economic and process evaluations. Setting Secondary schools in Scotland, England and Wales with above-average proportion of pupils eligible for free school meals. Randomisation occurred within schools (year-group level), using block randomisation stratified by school. Participants Pupils aged 11-13 years at recruitment, who have their own mobile telephone. Interventions Two-component intervention based on behaviour change theory: (1) 50-minute lesson delivered by teachers, and (2) twice-daily text messages to pupils' mobile phones about toothbrushing, compared with routine education. Main outcome measures Primary outcome: presence of at least one treated or untreated carious lesion using DICDAS4-6MFT (Decayed, Missing and Filled Teeth) in any permanent tooth, measured at pupil level at 2.5 years. Secondary outcomes included: number of DICDAS4-6MFT; presence and number of DICDAS1-6MFT; plaque; bleeding; twice-daily toothbrushing; health-related quality of life (Child Health Utility 9D); and oral health-related quality of life (Caries Impacts and Experiences Questionnaire for Children). Results Four thousand six hundred and eighty pupils (intervention, n = 2262; control, n = 2418) from 42 schools were randomised. The primary analysis on 2383 pupils (50.9%; intervention 1153, 51.0%; control 1230, 50.9%) with valid data at baseline and 2.5 years found 44.6% in the intervention group and 43.0% in control had obvious decay experience in at least one permanent tooth. There was no evidence of a difference (odds ratio 1.04, 95% confidence interval 0.85 to 1.26, p = 0.72) and no statistically significant differences in secondary outcomes except for twice-daily toothbrushing at 6 months (odds ratio 1.30, 95% confidence interval 1.03 to 1.63, p = 0.03) and gingival bleeding score (borderline) at 2.5 years (geometric mean difference 0.92, 95% confidence interval 0.85 to 1.00, p = 0.05). The intervention had higher incremental mean costs (£1.02, 95% confidence interval -1.29 to 3.23) and lower incremental mean quality-adjusted life-years (-0.003, 95% confidence interval -0.009 to 0.002). The probability of the intervention being cost-effective was 7% at 2.5 years. However, in two subgroups, pilot trial schools and schools with higher proportions of pupils eligible for free school meals, there was an 84% and 60% chance of cost effectiveness, respectively, although their incremental costs and quality-adjusted life-years remained small and not statistically significant. The process evaluation revealed that the intervention was generally acceptable, although the implementation of text messages proved challenging. The COVID-19 pandemic hampered data collection. High rates of missing economic data mean findings should be interpreted with caution. Conclusions Engagement with the intervention and evidence of 6-month change in toothbrushing behaviour was positive but did not translate into a reduction of caries. Future work should include work with secondary-school pupils to develop an understanding of the determinants of oral health behaviours, including toothbrushing and sugar consumption, particularly according to free school meal eligibility. Trial registration This trial is registered as ISRCTN12139369. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/166/08) and is published in full in Health Technology Assessment; Vol. 28, No. 52. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Zoe Marshman
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Hannah Ainsworth
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Caroline Fairhurst
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Katie Whiteside
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Debbie Sykes
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Anju Keetharuth
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sarab El Yousfi
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Emma Turner
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Peter F Day
- School of Dentistry, University of Leeds, Leeds, UK
- Community Dental Service, Bradford District Care NHS Foundation Trust, Bradford, UK
| | | | - Simon Dixon
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ian Kellar
- School of Psychology, University of Leeds, Leeds, UK
| | - Fiona Gilchrist
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | | | - Sue Pavitt
- School of Dentistry, University of Leeds, Leeds, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Donna Dey
- School of Humanities, Social Sciences and Law, University of Dundee, Dundee, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Lesley Pollard
- Children and Young People's Empowerment Project, Sheffield, UK
| | - Emma Manser
- Children and Young People's Empowerment Project, Sheffield, UK
| | - Nassar Seifo
- School of Dentistry, University of Dundee, Dundee, UK
| | | | | | - Claire Jones
- School of Medicine, University of Dundee, Dundee, UK
| | - Kate Hicks
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Nicola Innes
- School of Dentistry, Cardiff University, Cardiff, UK
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Innes N, Fairhurst C, Whiteside K, Ainsworth H, Sykes D, El Yousfi S, Turner E, Chestnutt IG, Keetharuth A, Dixon S, Day PF, Seifo N, Gilchrist F, Hicks K, Kellar I, Al-Yaseen W, Araujo M, Dey D, Hewitt C, Pavitt S, Robertson M, Torgerson D, Marshman Z. Behaviour change intervention for toothbrushing (lesson and text messages) to prevent dental caries in secondary school pupils: The BRIGHT randomized control trial. Community Dent Oral Epidemiol 2024; 52:469-478. [PMID: 38189629 DOI: 10.1111/cdoe.12940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/04/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVES This multicentre, assessor-blinded, two-arm cluster randomized trial evaluated the clinical and cost-effectiveness of a behaviour change intervention promoting toothbrushing for preventing dental caries in UK secondary schools. METHODS Pupils aged 11-13 years with their own mobile telephone attending secondary schools with above average free school meals eligibility were randomized (at year-group level) to receive a lesson and twice-daily text messages or to usual care. Year-groups (n = 84) from 42 schools including 4680 pupils (intervention, n = 2262; control, n = 2418) were randomized. RESULTS In 2383 participants with valid data at baseline and 2.5 years, the primary outcome of presence of at least one treated or untreated carious lesion (D4-6 MFT [Decayed, Missing and Filled Teeth] in permanent teeth using International Caries Detection and Assessment System) was 44.6% in the intervention group and 43.0% in control (odds ratio [OR] 1.04, 95% CI 0.85-1.26, p = .72). There were no statistically significant differences in secondary outcomes of presence of at least one treated or untreated carious lesion (D1-6 MFT), number of D4-6 MFT and D1-6 MFT, plaque and bleeding scores or health-related- (Child Health Utility 9D) or oral health-related- quality of life (CARIES-QC). However, twice-daily toothbrushing, reported by 77.6% of pupils at baseline, increased at 6 months (intervention, 86.9%; control, 83.0%; OR 1.30, 95% CI 1.03-1.63, p = .03), but returned to no difference at 2.5 years (intervention, 81.0%; control, 79.9%; OR 1.05, 95% CI 0.84-1.30, p = .69). Estimated incremental costs and quality-adjusted life-years (QALYs) of the intervention, relative to control, were £1.02 (95% CI -1.29 to 3.23) and -0.003 (95% CI -0.009 to 0.002), respectively, with a 7% chance of being cost-effective (£20 000/QALY gained threshold). CONCLUSION There was no evidence of statistically significant difference for caries prevalence at 2.5-years. The intervention's positive 6-month toothbrushing behaviour change did not translate into caries reduction. (ISRCTN 12139369). COVID-19 pandemic adversly affected follow-up.
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Affiliation(s)
- Nicola Innes
- School of Dentistry, Cardiff University, Cardiff, UK
| | - Caroline Fairhurst
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Katie Whiteside
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Hannah Ainsworth
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Debbie Sykes
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Sarab El Yousfi
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Emma Turner
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Anju Keetharuth
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Simon Dixon
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Peter F Day
- School of Dentistry, University of Leeds, Leeds, UK
- Community Dental Service, Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Nassar Seifo
- School of Dentistry, University of Dundee, Dundee, UK
| | - Fiona Gilchrist
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Katie Hicks
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Ian Kellar
- Department Psychology, University of Sheffield, Sheffield, UK
| | | | | | - Donna Dey
- School of Humanities, Social Sciences and Law, University of Dundee, Dundee, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Sue Pavitt
- School of Dentistry, University of Leeds, Leeds, UK
| | | | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Zoe Marshman
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
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Carpenter SM, Greer ZM, Newman R, Murphy SA, Shetty V, Nahum-Shani I. Developing Message Strategies to Engage Racial and Ethnic Minority Groups in Digital Oral Self-Care Interventions: Participatory Co-Design Approach. JMIR Form Res 2023; 7:e49179. [PMID: 38079204 PMCID: PMC10750234 DOI: 10.2196/49179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/01/2023] [Accepted: 08/25/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND The prevention of oral health diseases is a key public health issue and a major challenge for racial and ethnic minority groups, who often face barriers in accessing dental care. Daily toothbrushing is an important self-care behavior necessary for sustaining good oral health, yet engagement in regular brushing remains a challenge. Identifying strategies to promote engagement in regular oral self-care behaviors among populations at risk of poor oral health is critical. OBJECTIVE The formative research described here focused on creating messages for a digital oral self-care intervention targeting a racially and ethnically diverse population. Theoretically grounded strategies (reciprocity, reciprocity-by-proxy, and curiosity) were used to promote engagement in 3 aspects: oral self-care behaviors, an oral care smartphone app, and digital messages. A web-based participatory co-design approach was used to develop messages that are resource efficient, appealing, and novel; this approach involved dental experts, individuals from the general population, and individuals from the target population-dental patients from predominantly low-income racial and ethnic minority groups. Given that many individuals from racially and ethnically diverse populations face anonymity and confidentiality concerns when participating in research, we used an approach to message development that aimed to mitigate these concerns. METHODS Messages were initially developed with feedback from dental experts and Amazon Mechanical Turk workers. Dental patients were then recruited for 2 facilitator-mediated group webinar sessions held over Zoom (Zoom Video Communications; session 1: n=13; session 2: n=7), in which they provided both quantitative ratings and qualitative feedback on the messages. Participants interacted with the facilitator through Zoom polls and a chat window that was anonymous to other participants. Participants did not directly interact with each other, and the facilitator mediated sessions by verbally asking for message feedback and sharing key suggestions with the group for additional feedback. This approach plausibly enhanced participant anonymity and confidentiality during the sessions. RESULTS Participants rated messages highly in terms of liking (overall rating: mean 2.63, SD 0.58; reciprocity: mean 2.65, SD 0.52; reciprocity-by-proxy: mean 2.58, SD 0.53; curiosity involving interactive oral health questions and answers: mean 2.45, SD 0.69; curiosity involving tailored brushing feedback: mean 2.77, SD 0.48) on a scale ranging from 1 (do not like it) to 3 (like it). Qualitative feedback indicated that the participants preferred messages that were straightforward, enthusiastic, conversational, relatable, and authentic. CONCLUSIONS This formative research has the potential to guide the design of messages for future digital health behavioral interventions targeting individuals from diverse racial and ethnic populations. Insights emphasize the importance of identifying key stimuli and tasks that require engagement, gathering multiple perspectives during message development, and using new approaches for collecting both quantitative and qualitative data while mitigating anonymity and confidentiality concerns.
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Affiliation(s)
- Stephanie M Carpenter
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States
- Department of Psychology, University of Wisconsin-Madison, Madison, WI, United States
| | - Zara M Greer
- Oral and Maxillofacial Surgery, School of Dentistry, University of California, Los Angeles, Los Angeles, CA, United States
| | - Rebecca Newman
- Oral and Maxillofacial Surgery, School of Dentistry, University of California, Los Angeles, Los Angeles, CA, United States
| | - Susan A Murphy
- Department of Statistics, Harvard University, Cambridge, MA, United States
- Department of Computer Science, Harvard University, Cambridge, MA, United States
| | - Vivek Shetty
- Oral and Maxillofacial Surgery, School of Dentistry, University of California, Los Angeles, Los Angeles, CA, United States
| | - Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, Ann Arbor, MI, United States
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Ainsworth H, Marshman Z, Whiteside K, Sykes D, Fairhurst C, Turner E, Chestnutt I, Day P, Dey D, Elliott L, El-Yousfi S, Hewitt C, Jones C, Pavitt S, Robertson M, Torgerson D, Innes N. Set up and assessment of progression criteria for internal pilots: the Brushing RemInder 4 Good oral HealTh (BRIGHT) trial example. Pilot Feasibility Stud 2023; 9:17. [PMID: 36707907 PMCID: PMC9881267 DOI: 10.1186/s40814-023-01243-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 01/06/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Dental caries is common in young people and has wide-ranging ramifications for health and quality of life. Text messaging interventions show promise as a means to promote oral health behaviour change among young people. This paper reports the internal pilot of the Brushing RemInder 4 Good oral HealTh (BRIGHT) trial, which is evaluating an intervention comprising an oral health classroom lesson and text messages about toothbrushing, on caries in young people. Pilot trial objectives were to evaluate the feasibility and appropriateness of recruitment and data collection methods, the randomisation strategy, and intervention delivery against progression criteria for the main trial. METHODS This is an internal pilot trial embedded within an assessor-blinded, two-arm, cluster randomised controlled trial. Participants were pupils aged 11-13 years (in year 7/S1 or year 8/S2) in secondary schools in England, Scotland, and Wales with above average pupil eligibility for free school meals. Following completion of pupil baseline questionnaires and dental assessments, year groups within schools were randomised to the intervention or control arm. Approximately 12 weeks later, participants completed a follow-up questionnaire, which included questions about sources of oral health advice to assess intervention contamination between year groups. At the end of the pilot phase, trial conduct was reviewed against pre-specified progression criteria. RESULTS Ten schools were recruited for the pilot, with 20 year groups and 1073 pupils randomised (average of 54 pupils per year group). Data collection methods and intervention delivery were considered feasible, the response rate to the follow-up questionnaire was over 80%, there was an indication of a positive effect on self-reported toothbrushing, and interest was obtained from 80% of the schools required for the main trial. Despite partial intervention contamination between year groups, within-school randomisation at the level of the year-group was considered appropriate for the main trial, and the sample size was revised to account for partial contamination. Facilitators and barriers to recruitment and data collection were identified and strategies refined for the main trial. CONCLUSIONS Progression to the main trial of BRIGHT, with some design refinements, was concluded. The internal pilot was an efficient way to determine trial feasibility and optimise trial processes. TRIAL REGISTRATION ISRCTN registry, ISRCTN12139369 , registered 10/05/2017.
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Affiliation(s)
- Hannah Ainsworth
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Zoe Marshman
- grid.11835.3e0000 0004 1936 9262School of Clinical Dentistry, University of Sheffield, Claremont Crescent, Sheffield, UK
| | - Katie Whiteside
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Debbie Sykes
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Caroline Fairhurst
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Emma Turner
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Ivor Chestnutt
- grid.5600.30000 0001 0807 5670School of Dentistry, Cardiff University, Heath Park, Cardiff, UK ,grid.273109.e0000 0001 0111 258XCardiff and Vale University Health Board, Cardiff, UK
| | - Peter Day
- grid.9909.90000 0004 1936 8403School of Dentistry, University of Leeds, Leeds, UK ,grid.498142.2Bradford Community Dental Service, Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Donna Dey
- grid.8241.f0000 0004 0397 2876School of Education and Social Work, University of Dundee, Nethergate, Dundee, UK
| | - Louise Elliott
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Sarab El-Yousfi
- grid.11835.3e0000 0004 1936 9262School of Clinical Dentistry, University of Sheffield, Claremont Crescent, Sheffield, UK
| | - Catherine Hewitt
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Claire Jones
- grid.8241.f0000 0004 0397 2876Health Informatics Centre, University of Dundee, Dundee, UK
| | - Sue Pavitt
- grid.9909.90000 0004 1936 8403School of Dentistry, University of Leeds, Leeds, UK
| | - Mark Robertson
- grid.8241.f0000 0004 0397 2876School of Dentistry, University of Dundee, Park Place, Dundee, UK
| | - David Torgerson
- grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Nicola Innes
- grid.5600.30000 0001 0807 5670School of Dentistry, Cardiff University, Heath Park, Cardiff, UK
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