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Low-income older adults experience disparities in oral health problems, including caries and periodontal disease, that can exacerbate already high levels of chronic and acute health problems. Behavioral interventions have been shown to improve oral health status but are typically administered in institutional rather than community settings. Furthermore, multiple simultaneous interventions at different levels in the locations where people live and work are likely to have more impact and sustainability than single interventions in clinical settings.
This paper outlines a protocol for conducting a bilingual 5-year community-based trial of a bilevel intervention that addresses community norms, beliefs, intentions, and practices to improve oral health hygiene of vulnerable older adults living in publicly subsidized housing. The intervention utilizes (1) a face-to-face counseling approach (adapted motivational interviewing [AMI]) and (2) resident-run oral health campaigns in study buildings.
The study’s modified fractional factorial crossover design randomizes 6 matched buildings into 2 conditions: AMI followed by campaign (AB) and campaign followed by AMI (BA). The total intervention cycle is approximately 18 months in duration. The design compares the 2 interventions alone (T0-T1), and in different sequences (T1-T2), using a self-reported survey and clinical assessment to measure Plaque Score (PS) and Gingival Index (GI) as outcomes. A final timepoint (T3), 6 months post T2, assesses sustainability of each sequence. The intervention is based on the Fishbein integrated model that includes both individual and contextual modifiers, norms and social influence, beliefs, attitudes, efficacy, and intention as predictors of improvements in PS, GI, and oral health quality of life. The cognitive and behavioral domains in the intervention constitute the mechanisms through which the intervention should have a positive effect. They are tailored through the AMI and targeted to building populations through the peer-facilitated oral health campaigns. The sample size is 360, 180 in each condition, with an attrition rate of 25%. The study is funded by National Institute of Dental and Craniofacial Research (NIDCR) and has been reviewed by University of Connecticut and NIDCR institutional review boards and NIDCR’s clinical trials review procedures.
When compared against each other, the face-to-face intervention is expected to have greater positive effects on clinical outcomes and oral health quality of life through the mediators. When sequences are compared, the results may be similar but affected by different mediators. The arm consisting of the BA is expected to have better sustainability. The protocol’s unique features include the comparative effectiveness crossover design; the introduction of new emotion-based mediators; the balancing of fidelity, tailoring, and targeting; and resident engagement in the intervention.
If successful, the evaluated interventions can be scaled up for implementation in other low-income congregate living and recreational settings with older adult collectives.
ClinicalTrials.gov NCT02419144; https://clinicaltrials.gov/ct2/show/NCT02419144
DERR1-10.2196/14555
Older adults [
There continue to be significant ethnic and racial, class, and medical disparities with respect to oral disease, oral health care, and oral health–related quality of life [
Improving oral health of older adults, especially low-income and racial and ethnic minority adults who also suffer from disproportionate rates of chronic diseases such as cardiovascular disease and diabetes, is a primary national and international priority [
The approach described in this protocol offers important innovations with respect to public health dentistry and preventive oral health interventions for older adults. Public health dentistry typically does not tackle multilevel approaches to community-based prevention, especially with older adults. The study protocol describes a bilevel approach in line with the recognition that multilevel interventions in public health have greater impact and sustainability than single interventions. Furthermore, it is based on a theoretical framework, the Fishbein integrated model (IM) supplemented by Bandura’s notions of self-efficacy and practice to mastery [
The study uses adapted motivational interviewing (AMI), a more structured approach to motivational interviewing (MI) with individuals. MI has been found useful in individual level oral health and hygiene interventions with adults [
This paper describes the study protocol for the community-based clinical trial entitled: Good Oral Health—
Good Oral Health study theoretical framework. ADL: Activity of Daily Living; AMI: adapted motivational interviewing; CES-D: Center for Epidemiologic Studies Depression; GOHAI: General Oral Health Assessment Index. OH: oral health. * indicates AMI focal points and campaign messaging.
The study is based on a pilot intervention that evaluated the results of an individualized face-to-face AMI intervention combined with a resident-managed oral health campaign in one rent-subsided older adult building in central Connecticut [
The primary study aims are to evaluate the 2 main components of the intervention, the AMI and the oral health campaign, against each other and in different sequences and to assess the mechanisms (norms, beliefs, attitudes, intentions, and practice) through which the intervention operates at each time point.
The study hypotheses include the following: (1) the face-to-face intervention component of the overall intervention (AMI) will produce better short-term clinical outcomes and changes in mediators than the oral health campaign component; (2) the oral health campaign component followed by the individual component will produce better midterm and long-term clinical outcomes than the individual component followed by the oral health campaign; (3) the 2 sequences will result in differences in changes in the mediating cognitive domains at midterm; (4) within the face-to-face component, exposure to more mediating domains will result in better clinical outcomes; and (5) both conditions will have an equivalent effect on the secondary outcome—oral health quality of life at end point.
The study is a group randomized controlled trial (GRCT) in which 6 study buildings of between 125 and 375 apartment buildings housing independently living adults aged 62 years and older and people with disabilities are matched by size and randomized to one of 2 conditions (AMI followed by campaign [AB] and campaign followed by AMI [BA]), 3 buildings in each condition. In condition AB, the face-to-face intervention (A) precedes the oral health campaign (B) and in condition BA, the sequence is reversed. Buildings are selected based on size and geographic distance from one another; paired based on population age, ethnicity, and gender characteristics; and randomized by the study’s biostatistician. The procedure is described in the study protocol, which can be found on the study website [
Good Oral Health study design. AB: adapted motivational interviewing followed by campaign; AMI: adapted motivational interviewing; BA: campaign followed by adapted motivational interviewing. OHF: oral health fair.
The 6 study buildings are located in low-income areas of 3 Connecticut towns. The ethnic and racial composition of the population in these buildings consists of approximately 40% African American/Caribbean; 45% Latinos (mainly Puerto Ricans); and 10% to 15% other residents, mainly of European American or South/South East Asian origin. The rate of people with disabilities ranges from 15% to over 40%. To participate, buildings must have a common space and private locations for surveys and clinical assessments. Memoranda of agreements are signed with the managements of all buildings to guarantee participation and exempt building management from responsibility for any adverse intervention consequences. The study population speaks English, Spanish, or both. All materials used for recruiting, consenting, survey administration, and implementation of both intervention approaches are translated from English to Spanish and back translated to ensure that meaning in the 2 languages is preserved. Recruitment and all interventions are conducted in both languages or either language based on the participant’s choice.
The study population includes 360 residents, approximately 60 from each building, totaling 180 in each condition. The expected attrition rate over 4 time points is 25%. The inclusion criteria include (1) being aged 18 years and older, (2) having permanent residence (6 months or more) in study buildings, (3) living without conservator, (4) judged competent to give informed consent by responding correctly to 5 simple questions about the study during the consent process, and (5) 2 or more natural teeth. The exclusion criteria include (1) being temporary or short-term building resident; (2) being under conservatorship, (3) cognitively unable to give informed consent or respond to 3 to 5 questions about the study, (4) being edentulous; (5) having a history of infective endocarditis, prosthetic cardiac valve replacement in past 6 months, or insertion of an arterial stent or myocardial infarction in past 6 weeks or being on dialysis. The study is approved annually by the University of Connecticut Health institutional review board (IRB) and by NIDCR and Rho consultants.
Recruitment takes place during the first 5 to 6 months of each 18-month intervention period in each cycle. Recruiters are bilingual and of diverse ethnic and racial backgrounds, matching the backgrounds and languages of most participants. Steps in recruitment include initial discussions with building management, tenant associations, or other internal administrative bodies; 2 formal presentations to building residents, followed by presence on site several times a week; and informal engagement with residents and hosting of informal events, gatherings, and refreshments in community rooms and on building floors throughout the recruitment period. Public events sponsored by the study are conducted in communal spaces that can accommodate individuals with disabilities or in wheelchairs.
Participants found to be eligible are contacted within 2 to 3 days for an appointment to obtain informed consent and to conduct the clinical assessment. At the appointment, they are rescreened, informed about the study, and written consent is obtained. Consent forms are read to participants in English or Spanish, regardless of reading ability. Participants who are unable to read give verbal consent, which is recorded by the consenter and witnessed by a second member of the study staff. The signatures of both are recorded on the form with the participant’s name. Ineligible participants are invited to join an
Once consented, participants in the study are clinically assessed after which they are scheduled for a survey within the next 2 weeks. Retention is encouraged through continuous staff presence in the intervention buildings, phone calls and face-to-face reminders, home visits, casual encounters, flyers, face-to-face communication, and study-hosted social events such as bingo and ice cream socials throughout the study. These methods have been found to be useful for retention in prior studies on other health topics with similar populations in subsidized senior housing [
The 2 interventions are conducted orally and through demonstrations to accommodate those with limited literacy. Participation does not require the ability to read.
The individual-level intervention (AMI) is based on a successfully piloted 45-min adapted motivational interview protocol [
Cutoffs were developed during the pilot study by deciding whether domain mean scale scores or individual scale or index items were the best indicators of intervention need. These decisions are summarized in
Domain scales and cutoff scoring.
Domain | Scale description | Cutoff points | |
1. Activity of daily living | 8 items with response categories 0 (no help needed); 1 and 2 help needed. | Need help on any of these | |
|
7 items, true/false (Items in both scales are 4-point Likert scales from 1=strongly disagree to 4=strongly degree) | <5 correct | |
|
3b. Oral health self-efficacy | 5 items | >Mean of items <3 (disagree and strongly disagree) |
|
4b. Locus of control | 7 items (only 1 considered for cutoff) | If response to single item was agree or strongly agree |
3. Oral health norms: beliefs about importance of oral hygiene | 9 items, Likert scale with 4=very important and 1=not at all important. | 1 or 2 on any item (not at all important, not very important) | |
4. Oral health social support | 4 options (Likert scale with 0=no and 1=yes) | If all sources are |
|
5. Oral hygiene behaviors | 6 options (Likert scale with 1=never and 6=more than twice a day) | Brushing: <2 times per day; flossing: <1 time per day | |
6. Perceived oral health risks | 5 questions, 4-point Likert scale | Mean <3 (4=very unlikely, 3=unlikely, 2=likely, 1=very likely) | |
7. Self-management worries | 23 questions, 4-point scale, 1=very and 4=to not at all | Mean <3 for scale (4=not at all, 3=not much) | |
8. Self-management fears | 5 questions, 4-point Likert scale, 1=very to 4=not at all | Mean <3 (4=not at all, 3=not much) | |
9. Oral health self-management intentionality | 10 items, 3-point Likert scale (0=no, 1=some, 2=good possibility) | Mean <1 (0=no possibility, 1=slight possibility) | |
10. Dry mouth | 8 yes/no questions | Yes to at least one question | |
11. Diet | 5 items, 5-point Likert scale from never to >5 times daily. | >2-3 times a day on any item | |
12. Plaque Score/Gingival Index | Range from 0 to maximum of approximately 192 for each. | Mandatory for All participants regardless of score. |
To prepare for each AMI administration, the intervention facilitators create a file in advance, consisting of the completed intervention focal point check list, duplicates of a plan of action form, and the most recent clinical assessment showing the distribution of plaque.
The AMI is conducted in a private location in each building. Interventionists are required to address brushing and flossing and a minimum of 2 to 3 other cognitive or behavioral mediators. They record elements of the patient narrative in the Access data form and discuss each focal point with the participant using an interactive dialogue approach and referring to a standard script to correct misunderstandings, expand knowledge, and explore barriers to intention (knowledge, beliefs, and attitudes). To target brushing and flossing, interventionists show participants the results of their most recent plaque assessment and brief videos demonstrating techniques for brushing and flossing teeth. Participants then practice on a typodont and are scored for brushing, flossing, and denture cleaning techniques using a standardized skills assessment checklist, and scores are calculated from 1 to 4 for each (1=lowest, and 4=highest). The scoring is repeated until the participant achieves maximum improvement (practice to mastery), and the final score is recorded as a process evaluation data point. In the final step, interventionists review the discussion with the participant and help the participant to build a plan for addressing the main cognitive domains that impede their own oral health self-management and improving oral health hygiene behavior. Participants receive a copy of their plan, and a duplicate is kept in the file along with the focal point checklist, the Access focal points and PS data sheets and the skills assessment scored sheet. AMI administrations are audio recorded as a quality check with consent. Tailoring is accomplished through directing interventionist comments to the concerns raised in the participant’s opening narrative and the specific domains that require attention because of their low scores.
Fidelity to the AMI protocol is achieved through annual trainings, observation, and feedback on AMI delivery in each cycle. All AMI sessions are audio recorded with permission of the participant, and 10% of the recorded sessions are reviewed in every cycle in English and Spanish. Research charts are reviewed before filing to ensure case documentation such as recording cutoff domains, referral to a general study-approved script to address the domains, maintaining a hard copy and digital records of participant responses to domain-related discussions, participant concerns, and the participant plan. Furthermore, 10% of the research charts are reviewed every 6 months to ensure that intervention forms are complete.
The oral health campaign consists of 3 oral health fairs co-organized by a trained volunteer team of building residents (the campaign committee) that collaborates with bilingual study interventionists. The campaign protocol is based on the IM cognitive behavioral theory that guides the study, and processes derived from communications theory [
Efforts are made to attract both men and women representing the general pattern of diversity in each building for the campaign committee. As contributing participants in the study, they are asked to sign the IRB-approved consent forms agreeing to their participation as committee members. A small gift certificate and certificate of accomplishment are given to each committee member at the end of the campaign sequence in a public setting.
Committee members undergo a 12-session training program (see
Oral health campaign curriculum.
Sessions | Description |
Session 1 | Orientation and group identity |
Sessions 2-3 | Introduction to Good Oral Health campaign; protecting and respecting other residents |
Sessions 4-5 | Learning about oral health and hygiene self-management; creating a campaign event schedule |
Sessions 6-7 | Creating an oral health campaign plan |
Sessions 8-9 | Developing theoretically based materials and messages |
Session 10 | Preparing and practicing for campaign event |
Session 11 | Finalizing campaign posters |
Session 12 | Finalizing and practicing campaign roles and activities (including scripts for facilitating discussion at session tables, welcome station, passport administration, and signup sheets |
All residents in each building are invited to each of the campaigns, and they sign in at the door. Each attendee receives a passport that includes a space to check their presence at each message table. The passport records their name and exposure to and evaluation of each table visited. These data are entered into a computer database and provide (1) overall attendance of enrolled participants at each of 3 sessions, (2) unenrolled participants who attend each session (reach), (3) dosage (number of tables each participant visits at each campaign), and (4) whether they liked or did not like their experience at the table (acceptability). Passports of participants are placed in their research charts.
All oral health fairs are required to include the following:
Bilingual message tables, 1 per theoretical domain, with messages, games, activities, and/or handouts staffed with bilingual study staff and at least one campaign member.
A 15- to 30-min bilingual presentation by the dental hygienists on general issues of importance in oral health and hygiene maintenance.
A question-and-answer period in which members of the audience can raise questions with the speakers on any topic related to oral health in the language of their choice.
Resident members of the Campaign Committee and research staff are stationed at each domain table designed to foster discussions with each participant based on their questions, issues, and concerns related to the domain assigned to the table (eg, diet, worries about self-management, perceived risks associated with poor oral health, brushing, and flossing). These activities are followed by snacks, music, and prizes.
Sample size calculations were based on the primary outcomes of continuous measures of GI and PS using estimates of effect and variation from a pilot grant. The MFFD design has 2 sequences (AB and BA) and 2 periods (1 and 2). Power was based on the first period, which conceptually can be considered a 2-arm parallel design with cluster randomization at the building level. Assuming a typical intraclass correlation in the range of 0.01 or 0.02, a design with 6 clusters of n of 56 for each condition would have effective sample sizes of approximately 160 to 220, respectively [
The study evaluation design includes intervention moderators, mediators, process variables, and outcome measures. All alpha coefficients are from the study’s baseline data.
The primary outcomes are obtained through clinical assessments of oral hygiene status. The PS is a plaque scoring scheme developed by O’Leary et al [
The
Oral health knowledge is a 7-item true/false test based on a previously developed knowledge test used with low-income older African Americans [
Perceived oral health risks consists of 5 questions asking about the chances of getting cavities, cancer, toothache, gum problems, and hospitalization because of an oral health problem, on a 4-point scale from very unlikely (4) to very likely (1; Cronbach alpha coefficient=.761).
Oral health social support is assessed with 2 questions developed in the pilot study [
Who do you go to for health information in this building (check all that apply)? The responses are no one, other residents, building management, and people who come to provide services in the building. The scores range from 0 to 4.
How many residents do you talk to if you need information about health problems and how to handle them, not counting the building managers or others who work there? The responses are no one, 1 to 2, 3 to 4, and 5 or more. The scores range from 0 to 3.
Oral health beliefs include 2 subscales of the Dental Coping Beliefs Scale [
These are 2 new scales that include items identified by residents in focus groups, related to the topic. Both scales were piloted with good results during the pilot study phase (Oral Health Self-Management worries: Cronbach alpha coefficient=.90; Oral Health Self-Management fears: Cronbach alpha coefficient=.75). The
Oral health norms (perceived importance of actions) is measured with a 9-item scale that assesses the perceived importance of oral hygiene behavior from (very important 4) to not important at all (1; Cronbach alpha coefficient=.688).
Questions on frequency of brushing teeth, flossing teeth, and cleaning dentures. Responses to each are never (0), once a week (1), a few times a week (2), once a day (3), twice a day (4), and more than twice a day (5).
It uses the protocol described by Ajzen and Fishbein [
It is an index consisting of 8 questions with yes/no responses related to indicators of dry mouth adapted from a study by Gerdin et al [
It is an index that consists of 5 questions related to the consumption of sweet or starchy foods with responses including never (0), once in a day (1), 2 to 3 times a day (2), 4 to 5 times a day (3), and more than 5 times a day (4; Cronbach’s alpha coefficient=.619).
Intervention process variables include the number of focal points addressed in the intervention based on the total number of scores below the cutoff points for main cognitive and behavioral domains measured and addressed in the intervention; exposure to norms-based campaign measured with dosage (record of presence at event); and survey questions that record post exposure recognition of campaign messages including recalled participation in fairs, recognition of logos and messages, and perceived impact of fairs on self-management.
Items include age, gender, building, length of time in building, length of time in United States, marital status, race and ethnicity, current living arrangement, times moved in the past year, work status, religious engagement, income and income satisfaction, language use, telephone, transportation availability, home care, and health/dental health insurance.
Activities of daily living (ADLs) is a widely used measure of the physical functioning status of an individual. It consists of 8 behaviors that indicate ability to take care of personal basic needs [
Center for Epidemiologic Studies Depression (CES-D) Scale Short-Form is a 10-item short version of the CES-D screening instrument that measures depressive symptoms in community populations. The Spanish version of the 10-item CES-D has been validated for use with Puerto Rican older adults and used in several studies of older adults, including senior residents of public housing in the study area [
It consists of two indices: (1) an index assessing current health status based [
It is a single 4-point Likert scale of subjective oral health status [
All survey data are collected using the Questionnaire Development System (QDS) [
A comprehensive statistical plan addresses the modified fractional factorial crossover design. The usual inspection for outliers and influential data points is conducted along with summary statistics and evaluations of distributions of the data. In the case of nonnormal data, we use standard transformations (eg, log transformations) or explore alternatives (eg, nonparametric approaches or other distributions such as Poisson) or create categorical or nominal variables.
For period 1, the parallel-arm phase, standard approaches for a parallel 2-arm randomized study are conducted for the first period of the sequence, across all buildings. This analysis allows direct comparison of the AMI versus the campaign approach for clinical outcomes (study hypothesis 1). For periods 1 and 2, assessing sequence of interventions, study hypothesis 2, which sequence gives better clinical outcomes, are addressed using repeated-measures models. Depending on whether the outcome is continuous or dichotomous, we will use general linear mixed models or general estimating equations to fit a model with intervention and period effects using the MIXED procedure in SAS. Each set of measures from the same person (eg, gingival outcomes) is treated as a correlated cluster of data. An auto-correlation structure of 1 is likely to be appropriate. Customized contrasts can be constructed to make comparisons between time points. Time-varying covariates can be used in these models, and some missing data (under missing at random or missing completely at random assumptions where applicable) are allowable.
For baseline and health status variables, as this study randomizes at the level of site and individuals are not randomized, we will stratify some results (or adjust in models) for demographics such as age, gender, and marital status and individual characteristics such as health status, ADLs, depressive symptoms (CES-D), and oral health status (self-assessment). Any variable that shows potential for confounding or effect modification will be accounted for appropriately in all stages of the analysis.
For intervention variables, as all subjects are exposed to the same interventions, we will unpack the intervention into (1) dosage (percentage of talking points covered for all focal points —domains—addressed in the intervention and (2) exposure to focal point messages during campaigns. Study hypothesis 5 regarding dosage of interventions will be assessed by creating an ordinal scale that measures an individual’s exposure to talking points through participation in the AMI and exposure to messages via campaigns, thus creating a measure of dosage. We will then assess if dosage predicts better outcomes. This can be done directly (eg, compare mean gingival scores across dosage levels with analysis of variance) or dosage can be used as a predictor variable in the statistical models and causal pathway analyses. Practice to mastery (a 4-point Likert scale) and focal points (count variable) can be analyzed using similar techniques and approaches.
To address the secondary outcome of GOHAI, we will conduct a set of secondary analyses with GOHAI as a continuous outcome. It will also be incorporated into our statistical/mediator models as a predictor to see if it acts as an effect modifier.
To address cognitive mediators, the following variables will be incorporated into the causal pathway analysis to address example hypotheses 3 and 4: knowledge, oral health beliefs/norms, social support, oral hygiene behaviors, fears/worries, practice to mastery, and behavioral intentions. We will use longitudinal mediation to compare the two conditions (AMI followed by oral health campaign against oral health BA) in terms of whether they differ significantly in the amount of change that they engender in the GI and PS, indirectly through the mediators measured in our model.
We are interested in examining whether there is a change in our mediators over time, and if so, whether this change significantly leads to a change in behaviors, as assessed by the GI and PS. Recent methodological studies actually show that the analysis of change is more appropriately captured by specifying change (differences) in self-efficacy and our other mediators and behavioral outcomes between adjacent time points (ie, T2-T1 and T3-T2) as latent difference scores [
Hypothesis #3 will be tested using latent change score analysis specifying AMI and campaign as predictors of change in behavioral beliefs (ΔBB), OH social support (ΔSS), locus of control beliefs (ΔCB), self-efficacy (ΔSE), fears/worries (ΔF/W), social norms (ΔSN),practice to mastery (ΔP2M), and behavioral intentions (ΔBI) from baseline to first and second follow-up.
To test hypothesis 4, we will conduct dynamic mediation using latent change (difference) score mediation analysis. The analyses will be conducted in Mplus 7, where change (difference) scores representing differences in each mediator and outcome variable from baseline to final follow-up that is, T2-T1 (ΔT21) and T3-T2 (ΔT32) will be generated. It is the difference scores of the mediators and outcome variables that are modeled. Generally speaking, causal paths specifying latent (true) change, represented by change in knowledge, oral health beliefs/norms, oral health social support, oral hygiene behaviors, fears/worries, practice to mastery skills, and behavioral intentions in going from T1 to T2 and T2 to T3 will be specified, to predict change in GI and PS at T3 (ie, ΔGingival index32, ΔPlaque score32). To assess the impact of the change in self-efficacy (ΔSE), on changes in GI scores (ΔGingival index), direct and indirect paths from change in self-efficacy from baseline to first follow-up (ΔSE21) that predict the change in GI at the final follow-up (ΔGingival index32) will be specified and tested. Select direct and indirect paths from change scores of the other mediator variables to change scores of behavioral outcomes will also be specified in a similar fashion, and all these relationships will be tested simultaneously [
This study was funded in 2014, recruitment was initiated in mid 2015, after extensive reviews of the study, protocol and human subjects materials, as well as a full NIDCR 2 day site visit, as is normal for a U grant or cooperative agreement. All data collection was completed in July 2019, and analysis of the baseline data began in April 2019. Since the study is a clinical trial, the funders did not approve consideration of study data till all intervention data were collected by January 2019, to avoid any potential biasing of results. One paper summarizing the baseline association of moderators with study outcomes is in press, and another under review. Other papers are in process on the association of mediators with outcomes at baseline, changes from baseline to the first post assessment, evaluating one intervention approach against the other and diffusion effects of the oral health campaign to nonattenders.
Approximately 330,000 seniors or 16% of all public housing residents in the United States live in subsidized public housing and another 500,000 live in subsidized Section 8 housing [
The study’s modified fractional factorial approach disaggregates 2 components of a successful pilot intervention without the added expense of a control. Its comparative-effectiveness, crossover design allows for a comparison of the 2 primary components separately and together in different sequences. Finally, unlike many interventions, it adds a long-term sustainability component to evaluate which sequence has better sustaining power with respect to clinical and secondary outcomes. The GRCT design is implemented under maximally controlled conditions in a community setting, making it a model for community-based clinical trials.
Residents of low-income senior housing across the nation are very diverse. This protocol offers a bilingual approach that is culturally and individually tailored. All materials and research tools are developed, translated, and back translated for use in both English and Spanish, consistent with recommendations in the National Institutes of Health 2009 conference on interventions to improve oral health [
The study is also unique in its use of clinical assessments and biomarkers in a community residential setting. These assessments are cost-effective and have implications for clinical and research programs in other community settings. Finally, emotions are now understood to play a role in prevention and treatment adherence [
The intervention protocol should show potential for making much needed significant improvements in oral health behaviors of older adults (aged 62 years and older) and younger adults with disabilities (primarily aged 50-62 years) in publicly supported senior residences, especially as these rent-supported buildings now include up to 40% people with disabilities, an often unreached low-income population. Both interventions also can be implemented in senior centers or other places where older adults and people with disabilities gather, such as federally or state-funded lunch programs, and the AMI can be implemented easily and inexpensively at home as well. All of these opportunities can help to reduce the long-term need for acute dental care and treatment and can positively impact on diabetes and cardiovascular disease, which are problems associated with poor oral health in both of these vulnerable low-income populations.
Slide presentation detailing protocol components.
Peer-reviewer report from the National Institute of Dental and Craniofacial Research.
adapted motivational interviewing followed by campaign
activity of daily living
adapted motivational interviewing
campaign followed by adapted motivational interviewing
Center for Epidemiologic Studies Depression
Gingival Index
General Oral Health Assessment Index
group randomized controlled trial
integrated model
institutional review board
modified fractional factorial design
National Institute of Dental and Craniofacial Research
Plaque Score
Questionnaire Development System
None declared.