title: Developing a theory-based toolkit (the ‘STAR’ tool) to support supervised toothbrushing in the home in Scotland: a mixed-methods feasibility study
Creators: name: Fletcher, Emma
Publisher: name: University of Glasgow
Year: 2024

description: Background 
Despite improvements over the last several years, dental caries in children in Scotland is still high and large socioeconomic inequalities persist. These improvements (observed in the first year of school) are thought to be as a result of the universal supervised toothbrushing programme in nursery schools, which is part of Childsmile, Scotland’s national child oral health improvement programme. Many children, however, experience tooth decay before reaching nursery age (2- 3 years), prior to receiving the benefit of the nursery supervised toothbrushing programme - with the greatest burden of disease being experienced by children from the most socio-economically disadvantaged areas. Childsmile’s Dental Health Support Workers (DHSWs) provide tailored support to targeted families in the home setting, including the promotion of supervised toothbrushing in the early years. It is widely recognised that there are numerous social, environmental and family level barriers to positive toothbrushing behaviours but to date there have been no theory-based interventions targeted to more socio-economically disadvantaged families of very young children in the home setting. An existing behaviour change intervention to support parental supervised toothbrushing, called Uitblinkers, is in place in dental practices in The Netherlands delivered by dental therapists to families with children aged 2 to 10 years who attend practice, that has shown some promising results. This thesis describes the process of the development and feasibility testing of a new home-based toothbrushing tool, STAR, based on the Uitblinkers tool, delivered by Childsmile’s DHSWs to targeted families in Scotland. 

Methods 
The research process is underpinned by the use of a pragmatic approach and informed by elements from implementation science. The project is comprised of three studies. For the first study, an initial review of the literature was carried out to identify reported barriers to home toothbrushing for parents/carers with young children to inform the first round of a Delphi study. The aim of the Delphi was to reach consensus amongst experts on the most important barriers to parent/carer supervised toothbrushing and appropriate behaviour change techniques to address them. Purposive and snowball sampling identified an expert panel who completed a modified Delphi exercise consisting of two rounds. In the first Delphi round, an expert panel prioritised the most important barriers to include in the new tool, while in the second round the panel validated the most appropriate strategies to address these barriers. The second study utilised 12 qualitative in-depth interviews with DHSWs to seek feedback and insight into the potential barriers and facilitators to the use of the new toothbrushing tool. Interviews were analysed using framework analysis and mapped to the modified Consolidated Framework for Implementation Research (CFIR). Development of the content and resources for the new tool was undertaken and co-produced with DHSWs. Prototype cards and illustrations were designed alongside a graphic designer. This then resulted in the production of a prototype complete set of cards being produced to be tested out as part of the next study. As part of the third study, a two-day simulation workshop with four DHSWs and two parents tested the acceptability and feasibility of the tool. The simulated interactions between DHSWs and parents were video recorded and the conversational process was analysed and visually represented using the Functional Resonance Analysis Method (FRAM) - a novel approach in this area. Six exit interviews with six participants were also conducted and again analysed using framework analysis and CFIR. 

Results 
The literature review identified 18 relevant papers from which parent/carer home supervised toothbrushing barriers were collected. Twenty one experts ranked 11 out of 13 barriers as being important with ‘difficult child behaviour’ and ‘structures and routines’ being the most important. Twenty one experts ranked the strategies operant conditioning, stimulus-control, and goal-setting, as being appropriate approaches to tackle the barriers. DHSWs were positive about the use of the STAR tool, feeling it would be a useful addition to their current practice. The barriers included in the tool were relevant and reflected what they saw during home visits and strategies were thought to be helpful and would fit in with support they currently provide. Working alongside DHSWs, the STAR toothbrushing tool was then simulated with parents and DHSWs to investigate it feasibility and acceptability. DHSWs and parents responded positively to the use of the STAR tool and reported it was easy to use and adaptable to families with different barriers to toothbrushing. Six weeks follow-up found that parents had been able to use the strategies given to them to make beneficial changes to their toothbrushing routines. FRAM analysis showed that there was variation between DHSWs in how the STAR tool was used in action, in terms of both identifying toothbrushing barriers and delivering appropriate strategies. Each DHSW was able to complete each stage of the STAR process while still being able to incorporate their current Childsmile support. The STAR tool was able to be used flexibly by DHSWs to provide tailored toothbrushing advice to families. 

Conclusions 
This theory-based toolkit (The STAR tool) was developed to assist Childsmile DHSWs deliver tailored toothbrushing support to (targeted) parents/carers of young children in the home setting. The toolkit was feasible and acceptable to end users (both those delivering and those in receipt) and offered a flexible means of delivery dependent on the parents/carers level of need. A number of potential barriers to full scale roll out were identified during the process which may require additional considerations including DHSWs who only visit a family once, DHSWs who only carry out home visits when the child is very young and before toothbrushing has started, children with additional support needs and families in which English is not their first language. The STAR is currently being rolled out for use by DHSWs in the home setting and outcome and process evaluation is underway.