Feasibility and preliminary outcomes of a culturally adapted motivational interviewing intervention to reduce early childhood caries among children of two American Indian communities

Abstract

Objective

Early childhood caries (ECC) are prevalent among ethnic minoritized children in the US. Specifically, American Indian/Alaska Native (AI/AN) children face the highest burden of ECC compared to other children. Oral health (OH) interventions using adapted Motivational Interviewing (MI) to educate AI/AN parents/caregivers have demonstrated some promise. This study assessed the feasibility and short-term impact of a culturally adapted MI intervention designed for AI/AN pregnant women and mothers with young children.

Methods

We partnered with two tribal Community Advisory Boards who helped culturally tailor program materials including adapted MI sessions. Community Health Representatives (CHRs) from both tribes were trained in adapted MI and conducted the OH education sessions with eligible mothers. OH knowledge and attitude assessments were conducted before and after the adapted MI sessions.

Results

CHRs were able to recruit participants and implement the intervention as intended. Following the adapted MI sessions, we observed increases in general OH knowledge and modest increases in ratings of the importance of oral hygiene, oral self-efficacy, and perceived benefits of engaging in recommended OH behavior. No post-MI changes were observed in perceived severity of, or susceptibility to, OH problems.

Conclusions

This study demonstrated the feasibility of developing and implementing a culturally tailored, MI-based OH intervention for AI/AN caregivers, resulting in improved OH knowledge and self-efficacy. Given no significant change in other outcome variables, suggests a need for longer-term follow-up and integration with additional preventive strategies (e.g., fluoride varnish). Future research should explore the effectiveness of MI-based approaches in reducing ECC incidence over time.

Introduction

Background

Early childhood caries (ECC), defined as the presence of any missing, decayed, or filled tooth surface in primary teeth among children under six years old [1], is more prevalent among children with low socioeconomic status and within ethnic minoritized groups [2]. Caries burden is particularly high among American Indian and Alaska Native (AI/AN) children, who are more than 4 times more likely to have untreated ECC compared to white children [3].

One promising approach to reducing ECC in AI/AN children is by targeting caregivers using motivational interviewing. Motivational interviewing (MI) uses a collaborative approach between the participant and the interviewer to identify readiness to change specific behaviors [4]. MI can be administered by trained lay interviewers, and MI techniques have been adapted for OH promotion among AI/AN populations [4, 5]. There is evidence that MI is superior to didactic health education approaches for improving pediatric OH [6], but studies utilizing MI among Indigenous groups are mixed, with some showing evidence of decreased caries [7, 8] and others showing no benefit [9, 10]. The inconsistency of trial results suggests a gap in the research and clearly more work is necessary to evaluate the cultural relevance, feasibility, and acceptability of MI for OH promotion among AI/AN caregivers of young children.

Purpose of study

In an attempt to build upon best practices in the ECC prevention field, we conducted a feasibility study, called Great Beginnings for Healthy Native Smiles (GBHNS). More background information about the study can be found elsewhere [11, 12]. The GBHNS study objectives were to determine the cultural relevance and acceptability of the adapted MI approach paired with culturally tailored educational materials for women in two tribal communities. We aimed to study the relevance and acceptability of each MI intervention session by working with pregnant women (at least 3 months pregnant) and mothers with children up to 36 months old. Trusted community health workers, known as community health representatives (CHRs) in tribal communities, were trained and delivered the intervention. We sought to assess the short-term impact of culturally tailored OH intervention sessions on the OH knowledge, attitudes, beliefs, self-efficacy, and behavioral intentions of new mothers and caregivers. This study describes the results of this feasibility study and implications for future research that might reduce the prevalence of ECC among AI/AN children.

Methods

Setting

We partnered with two rural, AI/AN communities - one in the Southwestern US and one in the Northern Plains of the US to test our intervention to reduce ECC. The two tribes share similar contextual characteristics: they are relatively smaller tribes (15,000 members or less) located in rural/remote regions of the US, with a high prevalence of ECC, and limited resources available to address OH needs. While we selected two socially and culturally unique tribes, we did not intend to draw comparisons between the tribes and thus report findings in aggregate. The tribes had similar OH-relevant characteristics including geography, income level, access to and type of OH services available through Indian Health Service (IHS) as well as ECC prevalence. Tribe A (Northern Plains) has an IHS hospital and clinic, a Bureau of Indian Affairs, and the tribal government and tribal programs. While all enrolled tribal members are eligible to seek dental and medical services at the IHS facilities on the tribal nation, those who live off the tribal nation often have to travel a long distance (at least one hour away) for medical and social services. At the time of the study, Tribe A had a federally-funded Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) nutrition program that helped families provide healthy food for their children. Their tribal Head Start Program had lost funding and was not operational. The IHS dental clinic had one head dentist, two general practitioner dentists, one pediatric dentist, one Endodontist, one dental hygienist, and seven dental assistants. Tribe B (Southwest) is in a very rural area and many people who live on the reservation must travel 30–40 min for OH care at the IHS clinic on reservation, or as much as 150 miles for OH care services off reservation in nearby towns if they are referred out from IHS for specialty care. At the time of this study, seven dentists were stationed at the Health Center located on this reservation and at a satellite clinic that provided dental services. Tribe B’s Health Department served the community through several community-based programs: Dental Health, Behavioral Health, Cancer Support Services, the Health Promotion and Disease Prevention program, and the CHR Program. The tribe’s WIC program also helped families provide healthy food for their children. At the time of the study, the Head Start program also incorporated health, nutrition, education, family and community partnership, parent involvement, disabilities services, and mental health information into programs for almost 200 primarily low-income children ages 3–5.

Community Advisory Boards (CABs). Tribe A’s CAB was organized, recruited, and directed by two respected community members in partnership with the GBHNS team. The individuals recruited community members that were in Tribal health-related fields or expressed interest in the health field. The CAB would meet as a group independent from the GBHNS, as well as during regularly scheduled (virtual/in-person) meetings with the GBHNS team. Tribe B’s CAB was organized and recruited by a respected community health representative/GBHNS partner. A majority of CAB members at the time of the study worked for Tribal education or health-related programs and had interacted before the formation of the CAB. Both CABs contributed to adaptations of educational materials, survey tools, and adapted MI session content/priorities from their respected communities. The CABs met at least quarterly at each site each year. The GBHNS team updated both CABs on how the other approached a topic, what progress was being made, and any challenges/difficulties/successes each group experienced, but the two CABs did not meet together with the GBHNS team.

Intervention

Six 1-hour adapted MI OH educational intervention sessions were created with the help of the CAB at each site. Enrolled participants selected one of the 6 culturally tailored oral health intervention sessions to participate in. Session topics included: maternal OH, taking your child to the dentist, cleaning your infant’s mouth/brushing child’s teeth two times a day, limiting sweets/offer non-sugar foods and drinks, offering only plain water in bottles or sippy cups in bed, and reducing the sharing of objects that might spread germs. CHRs delivered the chosen session utilizing the adapted MI script and culturally tailored materials, along with the pre and post survey.

In contrast to the traditional open-ended structure of MI sessions, these were “adapted” sessions due to the utilization of community tailored oral health education scripts. In addition, MI relies on long term relationships between practitioners and participants. In this feasibility study, participants were present for only one session, limiting rapport development relative to standard MI. All sessions utilized MI principles (i.e. open ended questions, reflections, supporting autonomy, rolling with resistance, reflections, encouraging change talk), culturally tailored oral health information on a flipchart, and culturally relevant visuals.

The OH educational materials contained culturally tailored information pertaining to OH knowledge, attitudes, beliefs, practices, and perceived barriers to care pertinent to each of the tribal communities. We modeled the OH education materials on previously adapted educational materials, questionnaires, and interview guides from similar studies [9, 13–15]. Additional edits to the OH educational materials were made in partnership with the site teams (local CHRs and site coordinators) with feedback from the formative assessment and piloting of materials [11]. Each site created their own flipchart covering the same sessions. Finally, materials were edited iteratively by the CABs at each site until OH session materials were finalized for the current study in July 2022.

A consulting MI practitioner assisted the research team in creating the scripts for leading OH educational sessions. We modified language in the materials to better align with the values, attitudes, and practices related to pediatric OH in our partnering tribal study communities. For example, CAB recommendations requested that materials focus on local values and practices, community resources, and engaging the family. To accomplish this request, materials were adapted to show local cultural events and foods, and recommended specific locally available resources. To engage the family, some sessions recommended family modeling of oral health behaviors and the sharing of intervention session information with others.

Training of CHRs to deliver sessions

The recruited CHRs were already trained in multiple transferrable skill areas such as health communication, understanding chronic disease causes/prevention strategies, and handling sensitive health information. Importantly, they were respected and active members in their communities and knew their local language and community norms. This placed them in a unique position to be trained in core competencies of adapted MI and conduct the oral health education sessions with eligible mothers from their communities. CHRs had to meet availability requirements to achieve study benchmarks and conduct sufficient OH education sessions in the community. The CHRs also had experiences using different types of technology to accommodate the COVID-19 pandemic environment.

CHRs were trained in person by a Motivational Interviewer Network of Trainers (MINT) member, and by the university study team prior to the COVID-19 pandemic. Due to COVID-19 delays and a shift in the scope of the original study, a MI refresher was implemented for all CHRs. The refresher adapted MI trainings were conducted with the CHRs by two MI-trained study coordinators. The refresher trainings were held weekly for two months and lasted at least one hour per session. The virtual MI sessions designed for the CHRs were modeled after virtual classroom instruction implemented by the MINT trainer. Study coordinators utilized exercises and activities to teach MI core competencies of open-ended questions, affirmations, reflections, and summaries. Additional topics that were regularly covered in training sessions were the four steps of MI (engage, focus, evoke and plan). The CHRs also practiced sessions with a culturally tailored OH education flipchart covering the six OH topics (explained above). Utilizing feedback from the CHRs, personalized training activities were given to CHRs to gain confidence in adapted MI. As the CHRs gained confidence, a monthly group training session was implemented. The monthly group trainings allowed for CHRs to provide feedback to study coordinators on the process of MI and how it could be tailored for their specific communities.

Recruitment of participants

After completing the training sessions, CHRs recruited participants at each location. For the Southwest tribe (B), recruitment methods included door-to-door recruitment in villages, partnership with WIC and Head Start, referrals from other participants, flyers, word of mouth, and recruitment at local cultural events. For the Northern Plains tribe (A), recruitment methods included online recruitment via Facebook posts and messenger. In-person recruitment at both sites occurred at local events (i.e., pow wows, rodeos, sporting events), school information sessions, health fairs, and parks when the weather permitted. Word of mouth also brought in participants. Each week, each site would report time spent recruiting at various locations to determine the best recruitment areas for interested mothers. Eligibility requirements included: being a woman 18 years of age or older; either currently being pregnant or having a child under the age of 36 months; and being a member of one of the participating two tribes.

We aimed to recruit approximately five women to participate in each of the six OH sessions; we enrolled a total of 41 women who took part in the study. They each received one intervention session and we conducted a detailed process analysis of the cultural acceptability of each intervention session. Participants also completed a survey administered by the CHRs before and after receiving the MI session. Survey data were collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at NAU [16]. The CHRs audio recorded each intervention session which was later transferred to a secure server for fidelity monitoring and transcribed on https://trint.comfor further analysis. The research protocols, procedures and materials were reviewed and approved by the Northern Arizona University Human Research Protection Program and by the appropriate research review bodies of each Tribe. All study activities were conducted in acccordance with the Declaration of Helsinki (1964, 2024) guidelines.

Sociodemographics, transportation access and tribal identity

Prior to the MI session, we assessed age, education, income, race, ethnicity, marital status, tribal identity and tribal language fluency, along with access to health care transportation.

Overview of psychosocial assessments

We included a broad set of knowledge and attitude assessments developed by the Early Childhood Caries Collaborating Centers [17]. These assessments provide a standardized measurement approach to caregiver characteristics to facilitate comparisons across communities and have been included in a number of studies of caries in AI/AN children [18–22]. Summary scores were created for participants with sufficient numbers of valid items (see below). These assessments, collected before and after the adapted MI session, were intended to illustrate the process of participating in the motivational interviewing session rather than serve as formal study outcomes [23]. Thus, the statistical comparisons before and after the MI session are exploratory.

Oral health behavior

At baseline we included ten questions from an OH behavior scale [21], which assesses adherence to recommendations for good OH care. These items examine parental involvement in OH (brushing the child’s teeth, caregiver brushing practices), child consumption of sweets (sugary foods or drinks), and OH care utilization [21]. Items were scored as correct or incorrect (“don’t know” responses were scored as incorrect) and a percent correct score was calculated for respondents with 9 or 10 valid responses. Higher scores are associated with lower levels of childhood caries in AI/AN children aged 3–5 years [21].

Measures assessed before and after each motivational interviewing intervention session

We assessed OH knowledge with 16 questions used in previous studies of AI/AN caregivers [20]. Items encompass oral hygiene, diet, and preventive OH practices and include true/false questions, evaluations of whether certain behaviors are good for a child’s teeth or not (e.g., sharing a toothbrush, drinking soda), and questions about OH milestones (e.g., age when a child should stop drinking from a baby bottle, age when a child can brush their teeth alone). Responses were scored correct/incorrect, and percentage correct scores were calculated if there were 14 or more valid responses. Knowledge scores have been found to be related to higher caregiver education levels and better pediatric OH status [20].

A second OH knowledge assessment was based on seven study-specific knowledge questions. These were derived from content in the motivational interviewing scripts and were comprised of five true/false questions and two multiple choice questions, the latter questions assessing the first sign of tooth decay and the correct amount of toothpaste for children up to three years old. The percent correct was calculated for persons with valid responses for all items.

Oral health locus of control

Caregiver beliefs regarding control over their child’s OH status were assessed with nine items. This assessment [24, 25] encompassed personal control (e.g., if my child gets cavities then I am to blame), external-powerful other control (e.g., it’s the dentist’s job to keep my child from getting cavities), and external-chance (e.g., having good teeth is largely a matter of luck). Response options ranged from 1 (strongly disagree) to 5 (strongly agree) and were keyed so that higher scores reflect stronger internal locus of control. We created an overall locus of control summary score if respondents had seven or more valid items. Higher summary scores have been found to be inversely associated with untreated childhood caries [24].

Health belief model

We assessed four elements of the health belief model: perceived seriousness of dental caries, perceived barriers to recommended OH behavior, perceived susceptibility to OH problems and perceived benefits of recommended OH behavior [20, 21]. Items were rated on a scale from 1 (strongly disagree) to 5 (strongly agree) with higher scores reflecting greater degrees of the constructs.

Caregiver dental self-efficacy

We assessed caregiver’s confidence that they can engage in recommended care for their child’s teeth. Response options for this 12-item assessment ranged from not at all sure to extremely sure for behavior such as keeping your child from drinking sugary drinks and carefully checking your child’s teeth for spots and problems. An average score is computed with higher scores reflecting higher efficacy [20, 21].

Perceived importance of oral health care

To assess the perceived importance of recommended OH care, caregivers rated how important it was to engage in each of the behaviors described by the self-efficacy items. Response options ranged from not at all important (1) to extremely important (5) and an average was computed for participants with 12 valid items. Importance ratings may capture the motivation to engage in OH care and thus be sensitive to motivational interviewing [20, 21].

Fidelity measures

To monitor adapted MI fidelity, the Motivational Interviewing Integrity Coding (MITI 4.1) [26] was independently scored by two raters for each adapted MI OH session. When CHRs’ sessions were scored on the MITI 4.1 as “below proficiency,” personalized feedback was given to the CHRs. MI relies on constant upkeep of skills; the “low proficiency” items were the main topics in the personalized feedback that occurred after every scored session. The team practiced the upkeep of core MI components that are reflected in the scores of the MITI 4.1 such as cultivating change talk, empathy, giving information and asking questions.

Mapping of motivational interviewing content to oral health knowledge assessments

Each adapted motivational interviewing (MI) session was meant to be tailored to the participant’s lifestyle or specific OH inquiries as MI should never be strictly scripted. As previously explained, each OH adapted MI session was guided by a script which contained content specific to one of six topics: maternal OH; germs that cause cavities/reduce germ sharing; clean/brush 2x a day; take your child to the dentist; limit sweets-non-sugar food and drinks; offer only plain water. The scripts used by the CHRs were not explicitly designed to correspond with the oral health knowledge (OHK) survey questions, but instead were meant to serve as a framework for the sessions. Given this independence, we evaluated the MI session transcripts to identify overlap of OHK item content within the session script. We did this to bolster the internal validity of our evaluation of changes in oral health knowledge following the MI session.

We first identified 74 specific subtopics within the six broader MI session topics. Two independent coders evaluated whether or not (yes/no) the subcategory content could be used to correctly answer any of the OHK items. The coders practiced scoring the first three OHK items and then met to discuss their scores and address any ambiguities in the scoring process. After reaching a consensus on the first three items, the coders coded the remaining items independently. Following this coding, five coding discrepancies were identified and were resolved with discussion. Forty of the 74 subtopics were identified as containing OHK items.

To determine the extent to which the OHK content was delivered to participants during the sessions, we coded the presence or absence of the 40 OHK subtopics in the MI session transcripts. Two individuals coded each transcript, identifying the presence or absence (yes/no) of session-specific OHK items. Fifty coder disagreements were identified during this process. Coders discussed the discrepancies and agreed on a rating for these instances. After mapping OHK items from the survey to the scripts used in the adapted MI sessions, we identified the percentage of knowledge items shared with participants in each session by evaluating the transcripts. We identified the maximum number of possible knowledge items for each session (multiplied by the number of participants in each session) and used that to determine the percentage of the script-based OHK topics shared with the participants during the adapted MI sessions.

Results

Baseline characteristics and knowledge

Sample characteristics are presented in Table 1, along with descriptive statistics for tribal language use and tribal identity.

Table 1.

Caregiver sociodemographic and health characteristics (N = 41)

Characteristic	N	%
Age y, mean (SD)	27.4	6.5
Female gender	41	100.0
Relationship to child
Mother	41	100.0
Hispanic ethnicity
No	40	97.6
Yes	1	2.4
Race a
American Indian / Native American b	40	100.0
Alaska Native	0	0.0
Asian	0	0.0
Native Hawaiian	0	0.0
Other Pacific Islander	0	0.0
Black/African American	1	2.4
White	1	2.4
Other	2	4.9
Education level
< High school	6	14.6
High school diploma	18	43.9
Some college	13	31.7
College graduate or higher	4	9.8
Marital status
Married/cohabiting	5	12.2
Divorced	2	4.9
Separated	2	4.9
Never married	11	26.8
Member of an unmarried couple	16	39.0
Other	5	12.2
Work force status
Employed	19	46.3
Unemployed	9	22.0
Homemaker	3	7.3
Student	7	17.1
Other	3	7.3
Importance of maintaining your Tribal identity
Not at all	0	0.0
A little	1	2.4
Somewhat	9	22.0
Very much	31	75.6
Tribal language fluency
I don’t speak my tribal language	10	24.4
I speak it a little, but not very well	26	63.4
I speak it moderately well	4	9.8
I speak my tribal language very well	1	2.4
Income adequacy
Not enough to get by	4	9.8
Barely enough to get by	16	39.0
Sufficient to meet your needs	20	48.8
More than enough to meet your needs	1	2.4
Do you have access to a working vehicle?
No	9	22.0
Yes	32	78.0

Values are N and percent unless otherwise noted

^aResponses may include more than one category

^bOne participant did not endorse American Indian but did endorse membership in an eligible tribe

Knowledge elements included in the adapted MI sessions

Overall, CHRs were able to capitalize on 90% of the total knowledge opportunities across all six sessions.

For sessions one through six, CHRs provided 85% (22/26), 80% (28/35), 87% (47/54), 98% (44/45), 89% (64/72) and 100% (30/30) coverage of possible OH topics in the sessions, respectively.

Oral health behavior, knowledge, and health belief model, locus of control

The average score on the baseline OH behavior assessment was 51.5% correct (SD 23.8; range 10–90%, N = 39). The remaining assessments were obtained before and after the adapted MI intervention session - means and change scores are reported in Table 2. Both knowledge assessments improved following the MI intervention session. The 16-item knowledge measure increased from 77.1 to 91.7% (14.6% difference, 95%CI for difference: 9.6, 19.5) while the 7-item knowledge measure increased from 73.0 to 81.5% (8.5% difference, 95%CI for difference: 4.5%, 12.5%). Modest increases in perceived benefits of OH care, attitudes towards OH care and caregiver self-efficacy also occurred (Table 2), with the remaining measures unchanged following the intervention session.

Table 2.

Pre- and post-test assessments of oral health knowledge and beliefs

	Means		Difference	Post-pre	P
	Pre	Post	Mean	95% CI
Knowledge 1*, % correct (16 items)	77.1	91.7	14.6	(9.6, 19.5)	< 0.001
Knowledge 2†, % correct (7 items)	73.0	81.5	8.5	(4.5, 12.5)	< 0.001
Locus of control	36.0	36.4	0.39	(-1.3, 2.1)	0.633
Health belief model
Severity	4.4	4.4	-0.03	(-0.4, 0.3)	0.841
Susceptibility	3.1	3.3	0.16	(-0.1, 0.4)	0.285
Barriers	2.2	2.1	-0.07	(-0.4, 0.2)	0.624
Benefits	4.2	4.5	0.36	(0.1, 0.6)	0.005
Caregiver dental self-efficacy	4.5	4.7	0.15	(0.0, 0.3)	0.042
Perceived importance of oral health care	4.5	4.8	0.24	(0.1, 0.4)	0.002

*This was the knowledge assessment in Wilson et al. 2014 (20)

†This assessment was generated for the present study to align with the motivational interview scripts

Pre/post comparisons are paired t-tests. Locus of control scores were a sum of 9 items. The health belief model elements, caregiver dental self-efficacy and perceived importance of OH care were mean scores with higher scores reflecting greater levels of the construct. Sample sizes vary slightly across comparisons due to missing values (range 31 to 37)

Discussion

Key findings

In collaboration with two American Indian tribes, we developed and implemented a culturally adapted motivational interviewing approach to provide information regarding ECC prevention and promote recommended oral health care practices to AI/AN mothers and expectant mothers. The information was successfully delivered by tribal CHRs and was associated with short-term improvements in OH knowledge and smaller improvements in perceptions of the importance of recommended pediatric OH care and self-efficacy regarding participants’ ability to carry out these recommendations. We did not see significant pre/post changes in locus of control, perceptions of the severity of OH problems, susceptibility to OH problems or barriers to oral health care. This could be because the participants selected and received only one session and some session content did not overlap with these health belief domains.

Feasibility

The adapted MI sessions took place September 2022 to January 2023. Site coordinators removed transport barriers by allowing participants to choose their own date/time and meeting space. The site coordinators were well respected members of their communities prior to the initiation of the study. This respect from the community fostered trust and enabled us to recruit participants more readily. CHRs reported that the sessions were received well and that participants were very receptive to the new OH information. For example, two weeks post-intervention, this exchange occurred between one of the research staff and a participant. The research staff asked: “So you just told me a ton of information that you learned [in your session], which is amazing, but did any one of those things… have a real impact on you?” The participant responded: “Yeah, it did, because like I said, I didn’t know that I could’ve been brushing her gums prior to her teeth. And she had, she had just got like her teeth were just breaking through when we met with [CHR]. So like I had already bought, oh, the little like pens like, baby toothbrush and kind of one just to rub her teeth and stuff. But soon as she said that we started right away and literally we made it a goal. Like I started once a day brushing her teeth, her gums and like the teeth that was starting to break out. And now we’re up to two [a day]. It got us to start brushing her gums and teeth right away.” This is just one example, but we heard this multiple times (as reflected in our debriefing interviews, described in a forthcoming paper).

CHR recruitment was successful in terms of fulfilling study quotas in a timely fashion. In addition, both CABs remained intact for the length of the study. CABs were responsive to the study team for consultation and for study feedback. In comparing our work to other studies we and our colleagues have conducted previously, our CAB members were engaged through the duration of the study. This is a testament to the fact that we employed highly respected community members as our site coordinators who were champions for the project. Additional aspects such as building long-term relationships with a partnering community; community buy-in; CAB support; and overall connectedness with community interest were large drivers of success.

Comparisons to prior research

We used standard assessments of oral health knowledge and attitudes [17] to provide continuity with earlier work. Baseline OH knowledge scores in our study were comparable to scores using the same 16 items assessed in a previous study of AI/AN caregivers (77 vs. 75% correct, respectively) and with a similar 14-item knowledge assessment (74.5% correct) [20]. Thus, OH knowledge in our sample is comparable to larger studies of different AI/AN tribes, and these knowledge scores are associated with better pediatric OH status [20]. Overall, the short-term improvements in knowledge and attitudes are desirable steps towards improving pediatric and maternal oral health.

Tribal members serving as CHRs showed very high fidelity in terms of sharing topics in the MI scripts. While MI is generally participant-led and lacks a script or agenda, adapted educational MI can allow for more directed conversations and targeted educational goals. Using the scripts created for each session, CHRs employed MI features such as collaboration, cultivating change talk, and reaching benchmarks in each session. This approach was well received by participants and CHRs, was agreeable to the community representatives, and the improvements in OH knowledge indicate the promise of adapted MI for educational use in AI/AN communities. It is important to note that other OH promotion approaches, such as digital storytelling, can facilitate sharing of tribal history, rituals, traditional practices, and life experiences of elders and community members. This approach has been well received among First Nations and Métis families in Canada [27] and suggests another promising intervention avenue.

Implication for future research

OH partnerships within Indigenous US groups have incorporated MI as an element of a multifaceted prevention approach, but these have not reduced ECC [9, 10]. Taken together, it appears that prevention needs to start very early and incorporate additional preventive efforts such as fluoride varnish [7]. For example, fluoride varnish and MI was ineffective reducing ECC among 3–5 year old Indigenous children, perhaps because substantial ECC was evident before the intervention began [10]. Another rigorous but unsuccessful study using MI and targeting caregivers before and after the child’s birth did not incorporate fluoride varnish [9]. In contrast, a multicomponent prevention program starting before birth and incorporating fluoride varnish reduced ECC in Australian Indigenous children [7]. These intervention features inform future ECC prevention efforts among AI/AN populations.

Strengths and limitations of the study

Our study is subject to a number of limitations, including a small sample; a brief, single adapted MI session; the lack of a no treatment comparison group; and the potential for social desirability bias given the voluntary nature of participation and the community-engaged recruitment methods. Our findings may not generalize to other AI/AN groups, although baseline knowledge scores align with data from two other US tribes. The short-term OH knowledge improvements we observed may erode after longer intervals [9]. While the MITI 4.1 was used for fidelity monitoring for this adapted MI intervention, most sessions resulted in one or more of the MITI coders needing to provide feedback to the CHRs weekly. Thus, MI trainers dedicated an immense amount of time providing personalized feedback to ensure MI basics were followed. While this is a limitation in terms of MI performance, our staff and team were dedicated to constant feedback to improve MI skills in this educational intervention. We assessed a wide variety of OH-related attitudes and did not observe changes in locus of control and some of the health belief model components. The extent to which these are necessary for improving OH remain a question for future research.

This study has a number of strengths, including that it is one of only a few in the US that has developed culturally tailored ECC educational materials and utilized a community based participatory research approach [12]. Community members were an integral part of our research team and helped us to create and deliver the adapted MI intervention sessions. While MI can be quite time consuming and expensive to develop and implement in intervention studies, this feasibility study demonstrated some positive outcomes that indicate potential for and acceptability of this intervention approach.

Conclusion

This study adds to a growing body of research showing the acceptability and utility of MI to address ECC in AI/AN populations, and the importance of collaboration with tribal communities and health systems (including Indian Health Service) and culturally tailoring the educational materials. With just one adapted MI intervention session, we saw appreciable short-term improvements among mothers’ OH knowledge of recommended OH practices, and perceived importance of following recommended OH behaviors to prevent ECC in their children. This lends support to the potential impact of culturally tailored interventions and adapted MI to reduce ECC among AI/AN children and we hope that this approach might be adopted by other AI/AN communities. In addition, more longitudinal trials (including RCTs) are needed in the future to test the effectiveness of these culturally driven programs as compared to the current standard of care. As planned with our original RCT, we would recommend that a longitudinal trial that incorporates best practices in ECC and a multi-faceted approach consist of: (1) early intervention (i.e., while mothers are pregnant); (2) multiple adapted MI sessions over at least a year’s time (as described above), (3) family involvement; (4) consistent application of fluoride varnish as soon as infants have teeth; and (5) delivery of the program by trusted CHRs.

Author contributions

All authors contributed to writing-review, literature reviews and editing. JB, SDB, CK, CC, HT, SDB, SJB contributed to methodology, survey tool design, supervision. SDB, CH, CK, SJB, KB, CH conducted data analysis. KE, JB, CC, CK, GM, SY conducted formative assessment. SDB, CK, SJB, GM, SY, SH collected data. SDB, CH created Tables 1 and 2. JB, SDB, CK, SJB, SY, GM, SH oversaw project management. SY, GM, SH led participant recruitment/OH sessions. SJB, MT, CK adapted MI procedures. JB, CC, KE, CK, HT, SDB obtained resources and funding.

Funding

This study was funded by the National Institute for Dental and Craniofacial Research (NIDCR), U01DE028508.

Data availability

Sharing of these data requires the direct, expressed approval of the Tribes involved in this study and that of the PI, Dr. Julie Baldwin.  If you have further questions, please contact her at Julie.Baldwin@nau.edu.

Declarations

Ethics approvals and and consent to participate

This study was approved by the Northern Arizona University Institutional Review Board (#1902796-8) and by leadership of both participating Tribes. All participants provided written informed consent prior to participation. Study procedures were conducted in accordance with the U.S Office for Human Research Protections and the Declaration of Helsinki (1964; 2024).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.