Oral health: brush with me

Searching for health needs and influencing and leading professional practice to improve health (NMC, 2004) is an integral role of the specialist community public health nurse (SCPHN). As a student health visitor (HV) working in South Wales, it became apparent that improving oral health was an essential part of the role.

Oral diseases pose a significant health burden for many countries, with an estimated 3.5 billion people worldwide being affected (World Health Organization, 2020). However, although oral diseases are well known as being preventable, many families still struggle to prevent the occurrence of dental caries (Public Health Wales [PHW], 2017). The Welsh Oral Health Survey of five-year-olds found a correlation between deprivation and the increased likelihood of poor oral health (Cardiff University, 2016). Similarly, the UK Government has recognised that tackling poor oral health among children is a priority (Public Health England [PHE], 2018), as tooth decay is the most common reason children are admitted to hospital for a general anaesthetic (Knapp et al, 2017).

The current Welsh Designed to Smile programme (Welsh Government, 2017a) has made significant improvements in childhood caries since it began in 2009, with dental caries among five-year-olds falling from 47.6% in 2007-08 to 35.4% in 2014-15 (Cardiff University, 2016). As a student HV researching the incidence of dental decay among children in South Wales, I began reflecting on how to create easily disseminated interventions that may be used in conjunction with the Designed to Smile programme to help develop an improved culture of positive oral health and a reduction of caries among children. Interventions may include collaboration of resources, liaising with the local dentist, information sharing, encouraging early attendance at a dentist and providing books and activities to children (Welsh Government, 2017b).

The rhyme ‘Brush With Me’ was developed as an easily disseminated intervention for HVs, and includes important key messages encouraged by the Designed to Smile programme.

The hope is that providing families with this rhyme in the form of a placemat or book at the six-month HV contact may encourage an early but long-lasting awareness of the key positive oral health messages, while encouraging familial positive attachment, improved literacy and cognitive development.

During home assessments, HVs are in a positive position to disseminate this information, developing therapeutic relationships with families to improve their health and wellbeing. However, with each added pressure placed on a family living in deprivation, which is struggling financially and potentially eating less-nutritious food, it may be acknowledged that the capacity to engage with new activities may be at odds with the need to survive each day. It is prudent to acknowledge parental perspectives when developing any intervention aimed at improving health.

Parental Perspective

Recent research from a small focus group in an affluent area of South Wales found that parents were unanimous in their opinion that responsibility of children’s oral health remained with the family. However, parents were sometimes confused about some or all of the public health messages concerning oral health, with missed opportunities by HVs and school nurses in disseminating the key oral health messages being recognised (Coll et al, 2017). It should also be acknowledged that parental opinion may differ concerning the responsibility and practice of positive oral health, with research suggesting that those parents who do not recognise its importance, or those who do but are too busy or tired to apply it in the family home, have children with higher rates of dental caries (Duijster et al, 2015). Therefore, an opportunity for a behaviour change intervention was recognised for HVs to disseminate, with the aim of encouraging parental investment in positive oral health through easily accessible non-time-consuming family activities.

Poor child oral health is a priority, as tooth decay is the most common reason children are admitted to hospital for a general anaesthetic

Evidence supporting parental investment

Apart from the dissemination of positive oral health messages, reading to children helps strengthen the attachment between caregiver and child, and it has long been acknowledged that children who are read to regularly are more likely to have a wider understanding of language and vocabulary when entering pre-school (Levy et al, 2018). Furthermore, regular and consistent routines – such as keeping regular mealtimes, reading stories at bedtime and cutting down on screen time – can improve cognitive and behavioural development (Hernández-Alava and Popli, 2017).

Targeted interventions aimed at engaging families are key to initiating and encouraging lifestyle changes. Recognising and enabling people to develop the skills and knowledge to make positive life choices is developed through the World Health Organization’s three key elements: ‘Good governance for health’, ‘Health literacy’ and ‘Healthy cities’. This definition recognises that health promotion cannot just take place at an individual level, but needs good leadership with effective policies and people who are proactive to bring about change. HVs in Wales are proactive with the use of the Family Resilience Assessment Instrument Tool (FRAIT), which is used as part of key visits in the Healthy Child Wales programme (HCWP) (PRIME Centre Wales, 2017). This programme enables optimum analysis of family life to monitor and support child development. The FRAIT tool and the HCWP dovetail well with the Designed to Smile programme.

Making lifestyle changes

However, it can be difficult to engage families when using tools, written literature and media campaigns alone, as individual family circumstances go far beyond policies recommending that oral health information is disseminated and documented (Welsh Government, 2017b). Consideration of parental literacy skills, socioeconomic status and the confidence of the caregiver to engage with the activity needs to be acknowledged (Rouxel and Chandola, 2018). The HV’s role is not only to provide the information but to motivate the family to make positive lifestyle changes. HVs must engage in non-judgemental communication aimed at building therapeutic relationships with families to understand their motivations.

The development of Making Every Contact Count (MECC) (PHW, 2016) and the recommendation that motivational interviewing (Miller et al, 2013) is used by HVs to encourage behaviour change, demonstrate emphasis is being placed on autonomy and uncovering a ‘person’s [intrinsic] motivation to change’ (Day et al, 2017). Motivation for health professionals is often derived from seeing positive results.

For HVs, the motivation of the ‘Brush With Me’ rhyme lies with the knowledge that parents and children are learning the key messages for positive oral health in an easy and enjoyable way, with the added benefit of encouraging attachment and improving literacy skills. For parents, the motivation may be that they and their child are learning and enjoying time together while reaping the benefits of early awareness around the benefits of positive oral health.

*Information on other side of the placemat

HVs must engage in non-judgemental communication aimed at building therapeutic relationships with families to understand their motivations

If HVs are to encourage families to engage in new initiatives, such as the ‘Brush With Me’ rhyme, they need to look at the holistic situation of each family and seek to address poverty, poor access to education, low self-esteem and confidence, which are key reasons contributing to a lack of family engagement.

Positive oral health

Cwm Taf Morgannwg University Health Board will pilot the Brush With Me resources in the Bridgend area. It will target children on the author’s caseload at the six months contact stage, when a toothbrush, toothpaste and books from the Bookstart initiative are provided. Parents will be given the placemat and encouraged to read the rhyme with their child. All families taking part will be contacted at nine months and asked about their thoughts on the resources, whether they found them useful and their ease of use in the home. Should evaluation of the results indicate that there is a benefit in disseminating this information, hopefully its use will start in practice.

Although Brush With Me is a good resource and a starting point in engaging families in a lifetime of positive oral health, it cannot be used as a standalone structure to improve long-term oral health. The Welsh Government has previously recognised the importance of a collaborative approach from health professionals and the wider population to combat disease (Welsh Government, 2013). It is this knowledge that has structured its Prosperity for All strategy (Welsh Government, 2017c) bringing hope that a long-term multidisciplinary approach that combats poverty, smoking, obesity and sugar consumption and increases family resilience will reduce poor oral health, a preventable disease.

Carolyn Stapleton is a SCPHN health visitor at Cwm Taf Morgannwg University Health Board, and Dwynwen Spargo is senior lecturer and SCPHN course leader at the University of South Wales.

References:

Cardiff University. (2016). A picture of oral health: dental epidemiology survey of 5 year olds 2014/15. See: www.cardiff.ac.uk/__data/assets/pdf_file/0006/218589/Picture-of-Oral-Health-2016.pdf. (accessed 15 March 2022).

Coll AM, Richards W, Filipponi T. (2017) Exploring parents’ and teachers’ perceptions of promoting oral health in children. British Journal of School Nursing 12(4): 178-85.

Day P, Gould G, Hazelby G. (2017) The use of motivational interviewing in community nursing. Journal of Community Nursing 31(3): 59-63.

Duijster D, de Jong-Lenters M, Verrips E et al. (2015) Establishing oral health promoting behaviours in children: parents’ views on barriers, facilitators and professional support: a qualitative study British Medical Council Oral Health 15: 157.

Hernandez-Alava M, Popli G. (2017) Children’s development and parental input: evidence from the UK Millennium Cohort Study. Demography 54(2): 485-511.

Knapp R, Marshman Z, Rodd H. (2017) Treatment of dental caries under general anaesthetic in children. BDJ Team 4: 17116. See: https://eprints.whiterose.ac.uk/119288/1/BDJ_Open_caries_GA_final_amended.pdf (accessed 16 March 2022).

Levy, R, Hall M, Preece J. (2018) Examining the Links between Parents’ Relationships with Reading and Shared Reading with their Pre-School Children. International Journal of Educational Psychology 7(2): 123-50.

Miller WR, Rollnick S, McLouth CJ et al. (2012) Motivational Interviewing: Helping People Change. Guilford Press: New York City.

NMC. (2004) Standards for specialist community public health nurses. See: nmc.org.uk/standards/standards-for-post-registration/standards-of-proficiency-for-specialist-community-public-health-nurses/ (accessed 15 March 2022).

Public Health England. (2018) National Dental Epidemiology Programme for England: oral health survey of five-year-old children 2017. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/768368/NDEP_for_England_OH_Survey_5yr_2017_Report.pdf (accessed 15 March 2022).

Public Health Wales. (2016) Making every contact count. See: https://mecc.publichealthnetwork.cymru/en/ (accessed 15 March 2022).

Public Health Wales. (2017) Smiles all ‘round: children’s oral health improving in Wales. See: www.wales.nhs.uk/news/45378 (accessed 15 March 2022).

PRIME Centre Wales. (2017) Guidance for Family Resilience Assessment Instrument and Tool (FRAIT). See: www.primecentre.wales/resources/FRAIT%20Guidance.pdf (accessed 15 March 2022).

Rouxel P, Chandola T. (2018) Socioeconomic and ethnic inequalities in oral health among children and adolescents living in England, Wales and Northern Ireland. Community Dentistry and Oral Health 46(5): 426-34.

Welsh Government. (2013) Building a brighter future: early years and childcare plan. See: https://dera.ioe.ac.uk/18045/1/130716-building-brighter-future-en.pdf (accessed 15 March 2022).

Welsh Government. (2017a) Re-focussing of the Designed to Smile child oral health improvement programme. See: https://gov.wales/sites/default/files/publications/2019-07/re-focussing-of-the-designed-to-smile-child-oral-health-improvement-programme.pdf (accessed 15 March 2022).

Welsh Government. (2017b) Taking oral health improvement and dental services forward in Wales. See: https://gov.wales/sites/default/files/publications/2019-04/taking-oral-health-improvement-and-dental-services-forward-in-wales.pdf (accessed 15 March 2022).

Welsh Government. (2017c) Prosperity for all: economic action plan. See: https://gov.wales/prosperity-all-economic-action-plan (accessed 15 March 2022).

World Health Organisation. (2020) Oral health. See: who.int/news-room/fact-sheets/detail/oral-health (accessed 15 March 2022).

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