Cohort profile: South Australian Aboriginal Birth Cohort (SAABC)-a prospective longitudinal birth cohort

Interventions with pregnant women, new mothers and other primary caregivers for preventing early childhood caries

BACKGROUND

Dental caries, a common chronic disease of childhood, is associated with adverse health and economic consequences for infants and their families. Socioeconomically disadvantaged children have a higher risk of early childhood caries (ECC). This review updates one published in 2019.

OBJECTIVES

To assess the effects of interventions undertaken with pregnant women, new mothers or other primary caregivers of infants in the first year of life, for preventing ECC (from birth to six years).

SEARCH METHODS

We searched Cochrane Oral Health's Trials Register, Cochrane Pregnancy and Childbirth's Trials Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL EBSCO, the US National Institutes of Health Ongoing Trials Register (clinicaltrials.gov) and WHO International Clinical Trials Registry Platform (apps.who.int/trialsearch). The latest searches were run on 3 January, 2023.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing interventions with pregnant women, or new mothers and other primary caregivers of infants in the first year of life, against standard care, placebo or another intervention, reporting on a primary outcome: caries presence in primary teeth, dmfs (decayed, missing, filled primary surfaces index), or dmft (decayed, missing, filled teeth index), in children up to six years of age. Intervention types include clinical, oral health promotion/education (hygiene education, breastfeeding and other dietary advice) and policy or service.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, assessed risk of bias, and assessed certainty of evidence (GRADE).

MAIN RESULTS

We included 23 RCTs (5 cluster-randomised), involving 25,953 caregivers (mainly mothers) and their children. Fifteen trials assessed oral health education/promotion interventions against standard care. Six trials assessed a clinical intervention for mother dentition, against placebo, or a different type of clinical intervention. Two trials assessed oral health/education promotion plus clinical intervention (for mother's dentition) against standard care. At most, five trials (maximum of 1326 children and 130 mothers) contributed data to any comparison. Enamel-only caries were included in the diagnosis of caries in some studies. For many trials, the risk of bias was unclear due to lack of methodological details reported. In thirteen trials, participants were socioeconomically disadvantaged. No trial indicated receiving funding that was likely to have influenced their results. Oral health education/promotion interventions Child diet and feeding practice advice versus standard care: We observed a probable 15 per cent reduced risk of caries presence in primary teeth with the intervention (RR 0.85, 95% CI 0.75 to 0.97; 3 trials; 782 participants; moderate-certainty evidence), and there may be a slightly lower mean dmfs (MD -0.29, 95% CI -0.58 to 0; 2 trials; 757 participants; low-certainty evidence); however, the evidence is very uncertain regarding the difference between groups in mean dmft (MD -0.90, 95% CI -1.85 to 0.05; 1 trial; 340 participants; very low-certainty evidence). Breastfeeding promotion and support versus standard care: We observed little or no difference between groups in the risk of caries presence in primary teeth (RR 0.96, 95% CI 0.89 to 1.03; 2 trials; 1148 participants; low-certainty evidence) and in mean dmft (MD -0.12, 95% CI -0.59 to 0.36; 2 trials; 652 participants; low-certainty evidence). dmfs was not reported. Child diet advice compared with standard care: We are very uncertain about the effect on the risk of caries presence in primary teeth (RR 1.08, 95% CI 0.34 to 3.37; 1 trial; 148 participants; very low-certainty evidence). dmfs and dmft were not reported. Oral hygiene, child diet and feeding practice advice versus standard care: The evidence is very uncertain about the effect on the risk of caries presence in primary teeth (RR 0.73, 95% CI 0.50 to 1.07; 5 trials; 1326 participants; very low-certainty evidence) and there maybe little to no difference in mean dmfs (MD -0.87, 95% CI -2.18 to 0.43; 2 trials; 657 participants; low-certainty evidence) and mean dmft (MD -0.30, 95% CI -0.96 to 0.36; 1 trial; 187 participants; low-certainty evidence). High-dose versus low-dose vitamin D supplementation during pregnancy: We are very uncertain about the effect on risk of caries presence in primary teeth (RR 0.99, 95% CI 0.70 to 1.41; 1 trial; 496 participants; very low-certainty evidence). dmfs and dmft were not reported. Clinical interventions (for mother dentition) Chlorhexidine (CHX, a commonly prescribed antiseptic agent) or iodine-NaF application and prophylaxis versus placebo: We are very uncertain regarding the difference in risk of caries presence in primary teeth between antimicrobial and placebo treatment for mother dentition (RR 0.97, 95% CI 0.80 to 1.19; 3 trials; 479 participants; very low-certainty evidence). No trial reported dmfs or dmft. Xylitol compared with CHX antimicrobial treatment: We are very uncertain about the effect on caries presence in primary teeth (RR 0.62, 95% CI 0.27 to 1.39; 1 trial, 96 participants; very low-certainty evidence), but we observed there may be a lower mean dmft with xylitol (MD -2.39; 95% CI -4.10 to -0.68; 1 trial, 113 participants; low-certainty evidence). No trial reported dmfs. Oral health education/promotion plus clinical interventions (for mother dentition) Diet and feeding practice advice for infants and young children plus basic dental care for mothers compared with standard care: We are very uncertain about the effect on risk of caries presence in primary teeth (RR 0.44, 95% CI 0.05 to 3.95; 2 trials, 324 participants; very low-certainty evidence) or on mean dmft (1 study, not estimable). No trial reported dmfs. No trials evaluated policy or health service interventions.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that providing advice on diet and feeding to pregnant women, mothers or other caregivers with children up to the age of one year probably leads to a slightly reduced risk of early childhood caries (ECC). The remaining evidence is low to very-low certainty and is insufficient for determining which, if any, other intervention types and features may be effective for preventing ECC, and in which settings. Large, high-quality RCTs of oral health education/promotion, clinical, and policy and service access interventions, are warranted to determine the effects and relative effects of different interventions and inform practice. We have identified 13 ongoing studies. Future studies should consider if and how effects are modified by intervention features and participant characteristics (including socioeconomic status).

Against the use of the Strengths and Difficulties Questionnaire for Aboriginal and Torres Strait Islander children aged 2-15 years

OBJECTIVE

The Strengths and Difficulties Questionnaire is a widely used screening tool for emotional and behavioural problems in children. Recent quantitative analyses have raised concerns regarding its structural validity in Aboriginal and Torres Strait Islander communities. This paper aims to extend upon existing findings by analysing the factor structure of both the parent- and teacher-reported Strengths and Difficulties Questionnaire in this population across a broader age range than in previous studies.

METHODS

Participants were the caregivers and teachers of 1624 Aboriginal and Torres Strait Islander children (820 male, 804 female) aged 2-15 years from Waves 2-11 of the Longitudinal Study of Indigenous Children. The majority of children were Aboriginal living in major cities and inner regional areas. Internal consistency was estimated with McDonald's Omega. Exploratory structural equation modelling was conducted to investigate the factor structure of the parent-reported and teacher-reported versions of the Strengths and Difficulties Questionnaire.

RESULTS

Responses from teachers demonstrated higher internal consistency than responses from parents, which was unacceptably low across most age groups. The purported five-factor structure of the Strengths and Difficulties Questionnaire failed to be replicated across both parent- and teacher-reported questionnaires. The results of bifactor and hierarchical exploratory structural equation models also failed to approximate the higher-order summary scales. These results indicate that the Strengths and Difficulties Questionnaire subscales and summary scores do not provide a valid index of emotional and behavioural problems in Aboriginal and Torres Strait Islander children.

CONCLUSION

The Strengths and Difficulties Questionnaire should not be used with Aboriginal and Torres Strait Islander children.

Psychometric properties of the Social Support Scale (SSS) in two Aboriginal samples

In Australia, despite social support increasingly being reported as playing an important role in influencing health outcomes of Aboriginal and Torres Strait Islanders, measures of social support have not yet been validated for Aboriginal people. The current study aimed to evaluate the validity and reliability of the Social Support Scale in an Aboriginal and/or Torres Strait Islander population. The Social Support Scale (SSS) is a 4-item psychological instrument that was designed to evaluate four social support functions, instrumental, informational, emotional and appraisal support. Data included participants from two different samples: (1) Teeth Talk Study (n = 317), an oral-health randomized controlled trial (RCT) conducted with Aboriginal adults; and (2) the South Australian Aboriginal Birth Cohort Study (n = 367), a prospective longitudinal birth cohort study in which pregnant Aboriginal women were interviewed at baseline. The SSS psychometric properties were examined with Graphical Loglinear Rasch Models (GLLRM). The overall fit to a GLLRM was established (χ2(96)sample1 = 52.7, p = 0.06; χ2(25)sample2 = 22.2, p = 0.62) after accounting for local dependence between items 3 and 4. Item 2 displayed differential item functioning by employment status in Sample 1. Regarding dimensionality, the SSS was unidimensional in both samples (γobs1 = 0.80; γexp1 = 0.78, p = 0.65; γobs2 = 0.75, γexp2 = 0.77, p = 0.16). The instrument also displayed good reliability (Rsample1 = 0.82, Rsample2 = 0.84). Despite a few identified limitations (such as poor targeting), the findings indicated that the SSS is a promising instrument to provide culturally-valid and reliable measurement of social support among Aboriginal and/or Torres Strait Islander adults. Future studies should further investigate the instrument psychometric properties in other Aboriginal samples and the development and inclusion of culturally-sensitive items are also recommended.

Psychological Network of Stress, Coping and Social Support in an Aboriginal Population

Over the past decades, increasing research interest has been directed towards the psychosocial factors that impact Aboriginal health, including stress, coping and social support. However, there has been no study that examined whether the behaviours, cognitions and emotions related to stress, coping and social support constitute a psychological network in an Aboriginal population and that examined its properties. To address this gap, the current study employed a new methodology, network psychometrics, to evaluate stress, coping and social support in an Aboriginal Australian population. This study conducted a secondary analysis of the South Australian Aboriginal Birth Cohort (SAABC) study, a randomised controlled trial in South Australia, which included 367 pregnant Aboriginal women at study baseline. The Gaussian Graphical Model was estimated with least absolute shrinkage and selection operator (LASSO). Node centrality was evaluated with eigencentrality, strength and bridge centrality. Network communities were investigated with the walktrap algorithm. The findings indicated that stress, coping and social support constituted a connected psychological network in an Aboriginal population. Furthermore, at the centre of the network were the troubles experienced by the Aboriginal pregnant women, bridging their perceptions of stress and coping and constituting a potential target for future interventions.

Precision medicine via the integration of phenotype-genotype information in neonatal genome project

The explosion of next-generation sequencing (NGS) has enabled the widespread use of genomic data in precision medicine. Currently, several neonatal genome projects have emerged to explore the advantages of NGS to diagnose or screen for rare genetic disorders. These projects have made remarkable achievements, but still the genome data could be further explored with the assistance of phenotype collection. In contrast, longitudinal birth cohorts are great examples to record and apply phenotypic information in clinical studies starting at the neonatal period, especially the trajectory analyses for health development or disease progression. It is obvious that efficient integration of genotype and phenotype benefits not only the clinical management of rare genetic disorders but also the risk assessment of complex diseases. Here, we first summarize the recent neonatal genome projects as well as some longitudinal birth cohorts. Then, we propose two simplified strategies by integrating genotypic and phenotypic information in precision medicine based on current studies. Finally, research collaborations, sociological issues, and future perspectives are discussed. How to maximize neonatal genomic information to benefit the pediatric population remains an area in need of more research and effort.

A network psychometric validation of the Children Oral Health-Related Quality of Life (COHQoL) questionnaire among Aboriginal and/or Torres Strait Islander children

In Australia, research evidence has shown that Aboriginal and/or Torres Strait Islander children experience a higher burden of oral health diseases compared to other non-Indigenous children. The impact of oral health diseases on children's functional and psychosocial outcomes led to the development of several instruments to evaluate child oral health-related quality of life (COHQoL), such as the Parental-Caregiver Perception Questionnaire (P-CPQ) and the Family Impact Scale (FIS). However, the psychometric properties of these instruments have been evaluated only in Western cultures and have not been investigated for Aboriginal children in Australia. The current study aimed to examine the psychometric properties of the short-forms P-CPQ and FIS for Aboriginal and/or Torres Strait Islander children aged 2-3 years. Data were collected from the South Australian Aboriginal Birth Cohort (SAABC), including 270 Aboriginal children aged 2-3 years. Network psychometric models were used to investigate dimensionality, item redundancy, structural consistency and item stability, model fit, internal consistency reliability and criterion validity. We propose an instrument named Aboriginal Children's Oral Health-Related Quality of Life Questionnaire (A-COHQoL). Our findings indicated that, after the exclusion of four problematic items, the A-COHQoL showed a three-dimensional structure ("Parent/Family Activities", "COHQoL" and "Family Conflict") with good model fit and reliability. The A-COHQoL is a psychometrically robust and sensitive instrument that is readily available for Aboriginal and/or Torres Strait Islander children aged 2-3 years in Australia and can be adapted in the future for Indigenous child groups in other countries.

Child-, Family-, and Community-Level Facilitators for Promoting Oral Health Practices among Indigenous Children

Despite the preventive nature of oral diseases and their significance for general wellbeing, poor oral health is highly prevalent and has unfavourable ramifications for children around the world. Indigenous children in Australia experience disproportionate rates of early childhood caries compared to their non-Indigenous counterparts. Therefore, this paper aims to collate parental experiences and generate an understanding of facilitators for Indigenous childhood oral health. This project aggregated stories from parents of Indigenous children across South Australia who were participants in an early childhood caries-prevention trial. This paper explores facilitators for establishing oral health and nutrition behaviours for Indigenous children under the age of three through reflexive thematic analysis. Fisher-Owens' conceptual model for influences on children's oral health is utilised as a framework for thematic findings. Child-level facilitators include oral hygiene routines and regular water consumption. Family-level facilitators include familial ties, importance of knowledge, and positive oral health beliefs. Community-level facilitators include generational teaching, helpful community resources, and holistic health care. Recommendations from findings include the following: exploration of Indigenous health workers and elder participation in oral health initiatives; inclusion of Indigenous community representatives in mainstream oral health discussions; and incorporation of child-level, family-level, and community-level facilitators to increase support for efficacious oral health programs.

Aspirations and Worries: The Role of Parental Intrinsic Motivation in Establishing Oral Health Practices for Indigenous Children

Aboriginal and Torres Strait Islander (respectfully, subsequently referred to as Indigenous) children in Australia experience oral disease at a higher rate than non-Indigenous children. A history of colonisation, government-enforced assimilation, racism, and cultural annihilation has had profound impacts on Indigenous health, reflected in oral health inequities sustained by Indigenous communities. Motivational interviewing was one of four components utilised in this project, which aimed to identify factors related to the increased occurrence of early childhood caries in Indigenous children. This qualitative analysis represents motivational interviews with 226 participants and explores parents’ motivations for establishing oral health and nutrition practices for their children. Findings suggest that parental aspirations and worries underscored motivations to establish oral health and nutrition behaviours for children in this project. Within aspirations, parents desired for children to ‘keep their teeth’ and avoid false teeth, have a positive appearance, and preserve self-esteem. Parental worries related to child pain, negative appearance, sugar consumption, poor community oral health and rotten teeth. A discussion of findings results in the following recommendations: (1) consideration of the whole self, including mental health, in future oral health programming and research; (2) implementation of community-wide oral health programming, beyond parent-child dyads; and (3) prioritisation of community knowledge and traditions in oral health programming.

"What are we doing to our babies' teeth?" Barriers to establishing oral health practices for Indigenous children in South Australia

BACKGROUND

During the 1970s, optimal oral health was experienced more frequently amongst Indigenous children in Australia than their non-Indigenous counterparts. As a result of public health interventions targeting oral disease, oral health has improved for most children; however, Indigenous children today experience oral disease at alarmingly high rates. A history of colonisation, assimilation, racism and cultural annihilation has had profound impacts on oral health for Indigenous peoples; compounded by environmental dispossession and a shift from traditional diets to one of processed and nutrient-poor foods, often high in sugar.

METHODS

This project aimed to identify factors related to the increased occurrence of caries in Indigenous children. Using purposive sampling from the larger project, this paper thematically analyses 327 motivational interviews to explore current barriers impeding parental efforts to establish oral health and nutrition practices for Indigenous children. Representation of socioeconomic positions of families were compared across themes, as based on maternal age, employment, residency and number of children in care.

RESULTS

Findings resulted in a conceptual model of barriers that exist across knowledge, social, structural and parental factors. Major thematic results include: social consumption of processed foods, busy households, misleading nutrition marketing, sugar cravings and lack of oral health and nutrition knowledge.

CONCLUSION

A discussion of the findings results in the following recommendations increased oral health promotion efforts in non-metropolitan areas; utilisation of community experiences in creating strategies that encourage oral health and nutrition knowledge; and the extension of oral health initiatives and future research to include all family members. Trial registration Australian New Zealand Clinical Trial Registry ACTRN12611000111976; registered 01/02/2011.

Exploratory Graph Analysis of the Strengths and Difficulties Questionnaire for Aboriginal and/or Torres Strait Islander Children

In Australia, one of the most frequently used measures for assessing social and emotional well-being (SEWB) of Aboriginal and/or Torres Strait Islander children is the Strengths and Difficulties Questionnaire (SDQ). Previous studies on state-level validations have indicated the problems associated with the original five-factor SDQ structure, especially in the dimension of Peer Problems. The aim of this study was to use a novel psychometric methodology, namely Exploratory Graph Analysis (EGA), to evaluate the dimensionality of caregiver-informant SDQ version 4-10 years at a national level in Australia. Data for this study were retrospectively collected from two independent longitudinal studies: the Longitudinal Study of Indigenous Children (LSIC) and South Australian Aboriginal Birth Cohort (SAABC). The caregiver-informed SDQ version 4-10 years was applied across several study waves, including more than 4,000 responses. To conduct EGA, Gaussian graphical models (GGMs) were estimated using the Least Absolute Shrinkage and Selection Operator. About 2,500 bootstrap samples were also employed to investigate dimensions and item stability. The findings indicated robust evidence against the construct validity of the original five-factor SDQ structure. Future studies should conduct a direct external validation of the findings with Aboriginal and/or Torres Strait Islander parents/carers and community groups to develop the guidelines for future use of the instrument among Aboriginal and/or Torres Strait Islander children in Australia.