HHS Public Access Author manuscript Author Manuscript
Pediatr Dent. Author manuscript; available in PMC 2016 July 01. Published in final edited form as: Pediatr Dent. 2016 ; 38(1): 47–54.
Validation and Impact of Caregivers’ Oral Health Knowledge and Behavior on Children’s Oral Health Status Anne R Wilson, DDS, MS1, Angela G Brega, PhD2, Elizabeth Campagna, MS, PStat3, Patricia A Braun, MD, MPH4, William G Henderson, PhD3, Lucinda L Bryant, PhD2, Terrence S Batliner, DDS, MBA2, David O Quissell, PhD1, and Judith Albino, PhD2 1School
of Dental Medicine, University of Colorado Anschutz Medical Campus
Author Manuscript
2Colorado
School of Public Health, University of Colorado Anschutz Medical Campus
3Colorado
Health Outcomes Research Program, University of Colorado Anschutz Medical
Campus 4Children’s
Outcomes Research Program, University of Colorado Anschutz Medical Campus
Abstract Purpose—The purpose was to validate oral health knowledge and behavior measures from the Basic Research Factors Questionnaire, developed to capture specific themes contributing to children’s oral health outcomes and influence of caregivers.
Author Manuscript
Methods—Data were collected as part of a randomized clinical trial (N=992) aimed at reducing dental caries in young children. Participants were American Indian/Alaska Native caregivers with a child aged three to five years enrolled in a Navajo Nation Head Start Center. Caregivers completed the questionnaire at enrollment with concomitant evaluation of children for decayed, missing, and filled tooth surfaces (dmfs). Oral health knowledge and behavior outcomes were compared with convergent measures (participant sociodemographic characteristics, oral health attitudes, indicators of oral health status). Results—Caregiver oral health knowledge was significantly associated with education, income, oral health behavior, and all but one of the oral health attitude measures. Behavior was significantly associated with several measures of oral health attitudes and all but one measure of oral health status. As the behavior score improved, dmfs declined, child/caregiver overall oral health status improved, and pediatric oral health quality of life improved.
Author Manuscript
Conclusions—Questionnaire measures were valid for predicting specific caregiver factors potentially contributing to children’s oral health status.
Introduction Despite efforts to improve oral health of young children in the United States, disparities persist among groups identified as low socioeconomic status, and indigenous and ethnic minorities.1 Recent public health efforts to decrease childhood caries have focused on early preventive dental care and increased support from state and federal expansion of child health care insurance.2 Although access and resource allocation have improved, oral health disparities have increased among at-risk groups1,3 with American Indians/Alaska Natives
Wilson et al.
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Author Manuscript
(AI/AN) having the highest prevalence of childhood caries.4 Beyond general surveys of AI adults without delineation of caregiver status18, prior studies are not available regarding the influence of AI/AN caregivers’ oral health knowledge and behavior on oral health outcomes for children.12
Author Manuscript
Models developed to evaluate oral health outcomes among young children have traditionally focused on biologic and environmental influences with poor predictive results.5 New analytical approaches are recommended, emphasizing the multilevel nature of health determinants combining biologic, social, and behavioral determinants for the child-family unit.5–7 Such models acknowledge caregivers’ inextricable influence over the oral health of their young children.8 Accordingly, development of a validated caregiver instrument assessing a range of child-caregiver constructs related to children’s oral health outcomes has value for the AI/AN population and other at-risk groups for childhood caries. Consistent with prominent health behavior models and earlier studies9–12, variables expected to be associated with caregiver oral health knowledge and behavior were examined. Thus, the objective of this study was to validate oral health knowledge and behavior measures developed to capture specific themes contributing to children’s oral health outcomes in relation to AI caregivers. As such, this study provides an important step in validating oral health knowledge and behavior measures in a population with one of the highest risks for poor oral health outcomes. Ability to identify constructs associated with atrisk family-child units may inform future interventions aimed at reducing the lifelong impact of poor oral health established during early childhood.
Methods Author Manuscript
Study Approvals This study was approved by the Navajo Nation Human Research Review Board (NNHRRB), governing bodies at tribal and local levels, tribal departments of Head Start and Education, Head Start parent councils, and University of Colorado Multiple Institutional Review Board. This manuscript approved by the NNHRRB. All adult participants provided written informed consent before initiating study activities. Study Design
Author Manuscript
The study protocol was described in an earlier report13 and only key features are presented. The study was a cluster-randomized trial, with randomization at the level of the Navajo Nation Head Start Center (HSC). HSCs were stratified by agency (region of the reservation) and whether the HSC had one or multiple classrooms. The final sample included 39 HSCs (19 control and 20 intervention HSCs with 26 classrooms/group). Participants were recruited as caregiver-child dyads. Children were eligible if aged three to five years, enrolled in a participating HSC, and their parent/caregiver consented to participate. The Basic Research Factors Questionnaire (BRFQ), developed by The Early Childhood Caries Collaborating Centers (EC4), is a 190-item questionnaire assessing dental knowledge, attitudes, and behaviors of caregivers with young children. The BRFQ includes 23 oral health knowledge and behavior items, with remaining items encompassing Pediatr Dent. Author manuscript; available in PMC 2016 July 01.
Wilson et al.
Page 3
Author Manuscript
sociodemographic characteristics and psychosocial measures. Validation analyses were conducted to assess BRFQ measures of caregiver oral health and knowledge as related to childhood caries. Psychometric evaluation of remaining BRFQ items has been reported in prior studies.24,25
Author Manuscript
The BRFQ was administered on a computer with optional narration by a Navajo tribal member. Caregivers completed the BRFQ at enrollment and annually for two years with concomitant dental assessment of all children by calibrated evaluators to measure decayed, missing, and filled tooth surfaces (dmfs). Validation studies were conducted using baseline data from administration of the BRFQ at enrollment. A standardized calibration protocol required evaluators to complete calibration with a gold standard evaluator. Kappa scores were calculated from a minimum of 13 examinations. Calibration scores were independently analyzed to determine when kappa scores met or exceeded target thresholds. Evaluators had to achieve surface level kappa values of 0.40 or greater for demineralized lesions; 0.75 or greater for surface level cavitated lesions; and overall surface level kappa values of 0.70 or higher. All evaluators achieved kappa scores meeting or exceeding minimum required values. Measures
Author Manuscript
Construct validity, specifically convergent and divergent validity, determines relatedness among measures. Convergent validity determines the degree to which two measures expected to be related are indeed related. High correlation between measures is evidence of convergent validity. Divergent validity measures the degree that measures are unrelated. Analyses used baseline data to examine the association of oral health knowledge and behavior with various convergent measures. Based on earlier pilot work involving AI caregivers12, oral health knowledge and behavior were expected to be associated with each other and with specific sociodemographic characteristics. Consistent with prominent health behavior theories, Social Cognitive Theory9, 10 and the Health Belief Model10, oral health knowledge and behavior were expected to be associated with attitudes toward oral health and recommended oral health behaviors. Finally, knowledge and behavior were expected to be associated with indicators of oral health status.
Author Manuscript
Oral Health Knowledge and Behavior—Fourteen questions examined caregivers’ oral health knowledge and eleven questions examined adherence to recommended oral health behaviors. Responses were coded as correct or incorrect (“Don’t know” responses were identified as incorrect). An overall knowledge score was computed, represented as percentage of questions answered correctly. Responses were coded as adherent or nonadherent to oral health behavioral recommendations provided in the intervention. The overall behavioral adherence score reported percentage of behaviors for which caregivers were adherent. Convergent Measures Participant Characteristics: Items for sociodemographic characteristics included caregiver age and gender; caregiver educational attainment; and household income for the prior year.
Pediatr Dent. Author manuscript; available in PMC 2016 July 01.
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Oral Health Attitudes
Author Manuscript
Self-Efficacy: Twelve items were used to measure self-efficacy, a key construct from Social Cognitive Theory9, 10 representing an individual’s confidence in successfully engaging in recommended health behaviors. Some items were adapted from Reisine’s Dental Confidence Questionnaire14, and others newly developed. All items asked caregivers to indicate their confidence level in successfully engaging in recommended oral health behaviors. Items used a scale of 1–5, ranging from “not at all sure” to “extremely sure.” The average of selfefficacy items was computed for each participant. Larger numbers represented a greater degree of self-efficacy.
Author Manuscript
Perceived Importance of Recommended Oral Health Behavior: Twelve importance items were identical to self-efficacy items, except caregivers indicated how important it was to engage in each oral health behavior. Items used a scale of 1–5, ranging from “not at all important” to “extremely important.” For each participant, average of importance items was computed. Participant Locus of Control (LOC): Nine items assessed LOC, which represented caregivers’ beliefs regarding the source of control over their children’s oral health. Items were adapted from existing measures15, 16 to determine the extent to which caregivers agreed with statements indicating they were in control of their children’s oral health (Internal LOC), the dentist was in control (Powerful Others LOC), or their children’s oral health was a matter of chance (Chance LOC). Items used a scale of 1–5, where 1 represented “Strongly Disagree” and 5 represented “Strongly Agree.” For each type of LOC, the average of the three items assessing that domain was computed. Larger numbers for each subscale represented endorsement of that particular aspect of LOC.
Author Manuscript
Health Belief Model: Sixteen items measured four key constructs of the Health Belief Model.11,17 Key constructs included perceived susceptibility (caregivers’ perceptions that their children were susceptible to cavities), perceived seriousness (degree to which caregivers believed oral health problems were serious), and perceived benefits of and barriers to engaging in recommended oral health behaviors. Items were adapted from four sources18–21. Responses to all items ranged from 1 (“Strongly Disagree”) to 5 (“Strongly Agree”). The average of items associated with each construct was computed. Larger numbers represented a greater degree of each construct.
Author Manuscript
Indicators of Oral Health Status—Four measures were used as indicators of children’s oral health; a single measure assessed caregiver oral health. Using assessment data from baseline, dmfs scores were computed. Data collection procedures were described in a prior report22. An additional item, adapted from the National Survey of Children’s Health23, asked caregivers to rate their children’s oral health status as excellent, very good, good, fair, or poor. A parallel item asked caregivers to rate their oral health. Pediatric oral healthrelated quality of life (POQL) was assessed using a measure previously validated in AI participants24, 25 and other populations26. The range for POQL scores was 0–100, with lower scores indicating better POQL. Each caregiver was asked whether his/her child had
Pediatr Dent. Author manuscript; available in PMC 2016 July 01.
Wilson et al.
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Author Manuscript
seen “a dentist or other care provider for a cavity or toothache (not related to teething)” in the past year. Divergent Measures To demonstrate that positive associations for convergent measure were not spurious, BRFQ items expected to be unrelated to oral health knowledge and behavior were selected as divergent validity measures: baseline survey year (2011 or 2012), whether the HSC had single or multiple classrooms, and agency where the HSC was located (coded 1–5). Data Analysis
Author Manuscript
The association of oral health behavior and knowledge scores with demographics, social environment, psychosocial measures, child outcomes, and caregiver health/experiences was examined to assess construct validity. The alpha level for significance was ≤ 0.05. For categorical factors, the mean behavior or knowledge score was summarized within categories and compared using Analysis of Variance (ANOVA). For continuous measures, behavior and knowledge grouped by quartiles and treated as categorical. The mean measure within each quartile was compared using ANOVA.
Author Manuscript
Exploratory factor analysis (EFA) is commonly used to validate new measures. EFA examines relationships among items, and when similar items show evidence of clustering this represents face validity. Separate EFAs were used to examine the internal reliability and underlying the relationship of measured items related to oral health behavior and to oral health knowledge. The Kaiser-Guttman rule was used to select factors with eigenvalues greater than 1.0. Varimax, an orthogonal rotation, was applied to the factors to achieve a simpler structure by maximizing high loadings and minimizing low loadings. Factor loadings greater than 0.40 (absolute value) were considered to have a meaningful magnitude and ensured at least 16 percent of the item variance could be explained by the factor.27 The association of overall oral health knowledge and behavior measures with each convergent/divergent measure was assessed using ANOVA. For categorical measures, mean knowledge and behavior scores were summarized within categories. For continuous measures, the means of continuous measures were compared across quartile groups for oral health knowledge and behavior. Analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, NC, USA).
Author Manuscript
The final analysis sample included 992 dyads. Some analyses included fewer than 992 participants, due to unanswered questions. Missing data were minimal (ranging from 0–3.4 percent) except for two variables. Family income information was missing for 15.4 percent of dyads. Data on dental visits in the past year for treatment of a cavity or toothache were missing for 12.7 percent of dyads.
Results Caregiver and Child Sociodemographics The majority of caregivers were the child’s mother (77 percent), and the caregiver age range was 19–88 years (mean=32 years). Fifty-one percent of children were female, and the age Pediatr Dent. Author manuscript; available in PMC 2016 July 01.
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range was 3–5 years (mean=3.6 years). Eighty-four percent of caregivers had at least a high school diploma or GED, 61 percent had household incomes below $15,000, and 28 percent were employed. Ninety-eight percent of caregivers reported being AI, and 97 percent reported being members of the Navajo Nation. Ninety-nine percent of children were AI (remaining one percent were AN), and 95 percent were members of the Navajo Nation. Due to the small percentage of AN children and caregivers, the term, “AI” will be used henceforth in referring to the study population. Exploratory Factor Analysis (Table 1)
Author Manuscript
Factor loadings from EFA of oral health knowledge items resulted in seven factors with eigenvalues equal to or greater than one, which together accounted for 61 percent of the total variance; each factor explained seven to14 percent of the variance. Factors captured themes of (1) preventive care, (2) diet, (3) sharing germs, (4) fluoride use, (5) oral health milestones, (6) home care, and (7) cavities. The EFA for oral health behavior items resulted in four factors with eigenvalues equal to or greater than one, accounting for 57 percent of the total variance. Individual factors explained between nine to 19 percent of the variance. Factors captured the following: (1) dental care utilization, (2) caregiver involvement, (3) consumption of sweets, and (4) fluoride toothpaste use and nighttime oral practices. Internal Consistency Reliability The Cronbach alpha for the oral health knowledge scale was 0.51 and for behavior 0.55. Convergent Validity and Participant Characteristics (Table 2)
Author Manuscript
Overall oral health knowledge scores had a range of 21 to 100 percent (mean=74 percent). Female caregivers scored higher than males (p
Pediatr Dent. Author manuscript; available in PMC 2016 July 01. Published in final edited form as: Pediatr Dent. 2016 ; 38(1): 47–54.
Validation and Impact of Caregivers’ Oral Health Knowledge and Behavior on Children’s Oral Health Status Anne R Wilson, DDS, MS1, Angela G Brega, PhD2, Elizabeth Campagna, MS, PStat3, Patricia A Braun, MD, MPH4, William G Henderson, PhD3, Lucinda L Bryant, PhD2, Terrence S Batliner, DDS, MBA2, David O Quissell, PhD1, and Judith Albino, PhD2 1School
of Dental Medicine, University of Colorado Anschutz Medical Campus
Author Manuscript
2Colorado
School of Public Health, University of Colorado Anschutz Medical Campus
3Colorado
Health Outcomes Research Program, University of Colorado Anschutz Medical
Campus 4Children’s
Outcomes Research Program, University of Colorado Anschutz Medical Campus
Abstract Purpose—The purpose was to validate oral health knowledge and behavior measures from the Basic Research Factors Questionnaire, developed to capture specific themes contributing to children’s oral health outcomes and influence of caregivers.
Author Manuscript
Methods—Data were collected as part of a randomized clinical trial (N=992) aimed at reducing dental caries in young children. Participants were American Indian/Alaska Native caregivers with a child aged three to five years enrolled in a Navajo Nation Head Start Center. Caregivers completed the questionnaire at enrollment with concomitant evaluation of children for decayed, missing, and filled tooth surfaces (dmfs). Oral health knowledge and behavior outcomes were compared with convergent measures (participant sociodemographic characteristics, oral health attitudes, indicators of oral health status). Results—Caregiver oral health knowledge was significantly associated with education, income, oral health behavior, and all but one of the oral health attitude measures. Behavior was significantly associated with several measures of oral health attitudes and all but one measure of oral health status. As the behavior score improved, dmfs declined, child/caregiver overall oral health status improved, and pediatric oral health quality of life improved.
Author Manuscript
Conclusions—Questionnaire measures were valid for predicting specific caregiver factors potentially contributing to children’s oral health status.
Introduction Despite efforts to improve oral health of young children in the United States, disparities persist among groups identified as low socioeconomic status, and indigenous and ethnic minorities.1 Recent public health efforts to decrease childhood caries have focused on early preventive dental care and increased support from state and federal expansion of child health care insurance.2 Although access and resource allocation have improved, oral health disparities have increased among at-risk groups1,3 with American Indians/Alaska Natives
Wilson et al.
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Author Manuscript
(AI/AN) having the highest prevalence of childhood caries.4 Beyond general surveys of AI adults without delineation of caregiver status18, prior studies are not available regarding the influence of AI/AN caregivers’ oral health knowledge and behavior on oral health outcomes for children.12
Author Manuscript
Models developed to evaluate oral health outcomes among young children have traditionally focused on biologic and environmental influences with poor predictive results.5 New analytical approaches are recommended, emphasizing the multilevel nature of health determinants combining biologic, social, and behavioral determinants for the child-family unit.5–7 Such models acknowledge caregivers’ inextricable influence over the oral health of their young children.8 Accordingly, development of a validated caregiver instrument assessing a range of child-caregiver constructs related to children’s oral health outcomes has value for the AI/AN population and other at-risk groups for childhood caries. Consistent with prominent health behavior models and earlier studies9–12, variables expected to be associated with caregiver oral health knowledge and behavior were examined. Thus, the objective of this study was to validate oral health knowledge and behavior measures developed to capture specific themes contributing to children’s oral health outcomes in relation to AI caregivers. As such, this study provides an important step in validating oral health knowledge and behavior measures in a population with one of the highest risks for poor oral health outcomes. Ability to identify constructs associated with atrisk family-child units may inform future interventions aimed at reducing the lifelong impact of poor oral health established during early childhood.
Methods Author Manuscript
Study Approvals This study was approved by the Navajo Nation Human Research Review Board (NNHRRB), governing bodies at tribal and local levels, tribal departments of Head Start and Education, Head Start parent councils, and University of Colorado Multiple Institutional Review Board. This manuscript approved by the NNHRRB. All adult participants provided written informed consent before initiating study activities. Study Design
Author Manuscript
The study protocol was described in an earlier report13 and only key features are presented. The study was a cluster-randomized trial, with randomization at the level of the Navajo Nation Head Start Center (HSC). HSCs were stratified by agency (region of the reservation) and whether the HSC had one or multiple classrooms. The final sample included 39 HSCs (19 control and 20 intervention HSCs with 26 classrooms/group). Participants were recruited as caregiver-child dyads. Children were eligible if aged three to five years, enrolled in a participating HSC, and their parent/caregiver consented to participate. The Basic Research Factors Questionnaire (BRFQ), developed by The Early Childhood Caries Collaborating Centers (EC4), is a 190-item questionnaire assessing dental knowledge, attitudes, and behaviors of caregivers with young children. The BRFQ includes 23 oral health knowledge and behavior items, with remaining items encompassing Pediatr Dent. Author manuscript; available in PMC 2016 July 01.
Wilson et al.
Page 3
Author Manuscript
sociodemographic characteristics and psychosocial measures. Validation analyses were conducted to assess BRFQ measures of caregiver oral health and knowledge as related to childhood caries. Psychometric evaluation of remaining BRFQ items has been reported in prior studies.24,25
Author Manuscript
The BRFQ was administered on a computer with optional narration by a Navajo tribal member. Caregivers completed the BRFQ at enrollment and annually for two years with concomitant dental assessment of all children by calibrated evaluators to measure decayed, missing, and filled tooth surfaces (dmfs). Validation studies were conducted using baseline data from administration of the BRFQ at enrollment. A standardized calibration protocol required evaluators to complete calibration with a gold standard evaluator. Kappa scores were calculated from a minimum of 13 examinations. Calibration scores were independently analyzed to determine when kappa scores met or exceeded target thresholds. Evaluators had to achieve surface level kappa values of 0.40 or greater for demineralized lesions; 0.75 or greater for surface level cavitated lesions; and overall surface level kappa values of 0.70 or higher. All evaluators achieved kappa scores meeting or exceeding minimum required values. Measures
Author Manuscript
Construct validity, specifically convergent and divergent validity, determines relatedness among measures. Convergent validity determines the degree to which two measures expected to be related are indeed related. High correlation between measures is evidence of convergent validity. Divergent validity measures the degree that measures are unrelated. Analyses used baseline data to examine the association of oral health knowledge and behavior with various convergent measures. Based on earlier pilot work involving AI caregivers12, oral health knowledge and behavior were expected to be associated with each other and with specific sociodemographic characteristics. Consistent with prominent health behavior theories, Social Cognitive Theory9, 10 and the Health Belief Model10, oral health knowledge and behavior were expected to be associated with attitudes toward oral health and recommended oral health behaviors. Finally, knowledge and behavior were expected to be associated with indicators of oral health status.
Author Manuscript
Oral Health Knowledge and Behavior—Fourteen questions examined caregivers’ oral health knowledge and eleven questions examined adherence to recommended oral health behaviors. Responses were coded as correct or incorrect (“Don’t know” responses were identified as incorrect). An overall knowledge score was computed, represented as percentage of questions answered correctly. Responses were coded as adherent or nonadherent to oral health behavioral recommendations provided in the intervention. The overall behavioral adherence score reported percentage of behaviors for which caregivers were adherent. Convergent Measures Participant Characteristics: Items for sociodemographic characteristics included caregiver age and gender; caregiver educational attainment; and household income for the prior year.
Pediatr Dent. Author manuscript; available in PMC 2016 July 01.
Wilson et al.
Page 4
Oral Health Attitudes
Author Manuscript
Self-Efficacy: Twelve items were used to measure self-efficacy, a key construct from Social Cognitive Theory9, 10 representing an individual’s confidence in successfully engaging in recommended health behaviors. Some items were adapted from Reisine’s Dental Confidence Questionnaire14, and others newly developed. All items asked caregivers to indicate their confidence level in successfully engaging in recommended oral health behaviors. Items used a scale of 1–5, ranging from “not at all sure” to “extremely sure.” The average of selfefficacy items was computed for each participant. Larger numbers represented a greater degree of self-efficacy.
Author Manuscript
Perceived Importance of Recommended Oral Health Behavior: Twelve importance items were identical to self-efficacy items, except caregivers indicated how important it was to engage in each oral health behavior. Items used a scale of 1–5, ranging from “not at all important” to “extremely important.” For each participant, average of importance items was computed. Participant Locus of Control (LOC): Nine items assessed LOC, which represented caregivers’ beliefs regarding the source of control over their children’s oral health. Items were adapted from existing measures15, 16 to determine the extent to which caregivers agreed with statements indicating they were in control of their children’s oral health (Internal LOC), the dentist was in control (Powerful Others LOC), or their children’s oral health was a matter of chance (Chance LOC). Items used a scale of 1–5, where 1 represented “Strongly Disagree” and 5 represented “Strongly Agree.” For each type of LOC, the average of the three items assessing that domain was computed. Larger numbers for each subscale represented endorsement of that particular aspect of LOC.
Author Manuscript
Health Belief Model: Sixteen items measured four key constructs of the Health Belief Model.11,17 Key constructs included perceived susceptibility (caregivers’ perceptions that their children were susceptible to cavities), perceived seriousness (degree to which caregivers believed oral health problems were serious), and perceived benefits of and barriers to engaging in recommended oral health behaviors. Items were adapted from four sources18–21. Responses to all items ranged from 1 (“Strongly Disagree”) to 5 (“Strongly Agree”). The average of items associated with each construct was computed. Larger numbers represented a greater degree of each construct.
Author Manuscript
Indicators of Oral Health Status—Four measures were used as indicators of children’s oral health; a single measure assessed caregiver oral health. Using assessment data from baseline, dmfs scores were computed. Data collection procedures were described in a prior report22. An additional item, adapted from the National Survey of Children’s Health23, asked caregivers to rate their children’s oral health status as excellent, very good, good, fair, or poor. A parallel item asked caregivers to rate their oral health. Pediatric oral healthrelated quality of life (POQL) was assessed using a measure previously validated in AI participants24, 25 and other populations26. The range for POQL scores was 0–100, with lower scores indicating better POQL. Each caregiver was asked whether his/her child had
Pediatr Dent. Author manuscript; available in PMC 2016 July 01.
Wilson et al.
Page 5
Author Manuscript
seen “a dentist or other care provider for a cavity or toothache (not related to teething)” in the past year. Divergent Measures To demonstrate that positive associations for convergent measure were not spurious, BRFQ items expected to be unrelated to oral health knowledge and behavior were selected as divergent validity measures: baseline survey year (2011 or 2012), whether the HSC had single or multiple classrooms, and agency where the HSC was located (coded 1–5). Data Analysis
Author Manuscript
The association of oral health behavior and knowledge scores with demographics, social environment, psychosocial measures, child outcomes, and caregiver health/experiences was examined to assess construct validity. The alpha level for significance was ≤ 0.05. For categorical factors, the mean behavior or knowledge score was summarized within categories and compared using Analysis of Variance (ANOVA). For continuous measures, behavior and knowledge grouped by quartiles and treated as categorical. The mean measure within each quartile was compared using ANOVA.
Author Manuscript
Exploratory factor analysis (EFA) is commonly used to validate new measures. EFA examines relationships among items, and when similar items show evidence of clustering this represents face validity. Separate EFAs were used to examine the internal reliability and underlying the relationship of measured items related to oral health behavior and to oral health knowledge. The Kaiser-Guttman rule was used to select factors with eigenvalues greater than 1.0. Varimax, an orthogonal rotation, was applied to the factors to achieve a simpler structure by maximizing high loadings and minimizing low loadings. Factor loadings greater than 0.40 (absolute value) were considered to have a meaningful magnitude and ensured at least 16 percent of the item variance could be explained by the factor.27 The association of overall oral health knowledge and behavior measures with each convergent/divergent measure was assessed using ANOVA. For categorical measures, mean knowledge and behavior scores were summarized within categories. For continuous measures, the means of continuous measures were compared across quartile groups for oral health knowledge and behavior. Analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, NC, USA).
Author Manuscript
The final analysis sample included 992 dyads. Some analyses included fewer than 992 participants, due to unanswered questions. Missing data were minimal (ranging from 0–3.4 percent) except for two variables. Family income information was missing for 15.4 percent of dyads. Data on dental visits in the past year for treatment of a cavity or toothache were missing for 12.7 percent of dyads.
Results Caregiver and Child Sociodemographics The majority of caregivers were the child’s mother (77 percent), and the caregiver age range was 19–88 years (mean=32 years). Fifty-one percent of children were female, and the age Pediatr Dent. Author manuscript; available in PMC 2016 July 01.
Wilson et al.
Page 6
Author Manuscript
range was 3–5 years (mean=3.6 years). Eighty-four percent of caregivers had at least a high school diploma or GED, 61 percent had household incomes below $15,000, and 28 percent were employed. Ninety-eight percent of caregivers reported being AI, and 97 percent reported being members of the Navajo Nation. Ninety-nine percent of children were AI (remaining one percent were AN), and 95 percent were members of the Navajo Nation. Due to the small percentage of AN children and caregivers, the term, “AI” will be used henceforth in referring to the study population. Exploratory Factor Analysis (Table 1)
Author Manuscript
Factor loadings from EFA of oral health knowledge items resulted in seven factors with eigenvalues equal to or greater than one, which together accounted for 61 percent of the total variance; each factor explained seven to14 percent of the variance. Factors captured themes of (1) preventive care, (2) diet, (3) sharing germs, (4) fluoride use, (5) oral health milestones, (6) home care, and (7) cavities. The EFA for oral health behavior items resulted in four factors with eigenvalues equal to or greater than one, accounting for 57 percent of the total variance. Individual factors explained between nine to 19 percent of the variance. Factors captured the following: (1) dental care utilization, (2) caregiver involvement, (3) consumption of sweets, and (4) fluoride toothpaste use and nighttime oral practices. Internal Consistency Reliability The Cronbach alpha for the oral health knowledge scale was 0.51 and for behavior 0.55. Convergent Validity and Participant Characteristics (Table 2)
Author Manuscript
Overall oral health knowledge scores had a range of 21 to 100 percent (mean=74 percent). Female caregivers scored higher than males (p
